Provider Demographics
NPI:1104214816
Name:QUAIL CREST IMAGING, LLC
Entity Type:Organization
Organization Name:QUAIL CREST IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:785-856-0117
Mailing Address - Street 1:4830 QUAIL CREST PL STE B
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3842
Mailing Address - Country:US
Mailing Address - Phone:785-856-0117
Mailing Address - Fax:785-856-5082
Practice Address - Street 1:4830 QUAIL CREST PL STE B
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3842
Practice Address - Country:US
Practice Address - Phone:785-856-0117
Practice Address - Fax:785-856-5082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS69441223E0200X
KS63571223P0300X
KS600711223P0300X
KS1885124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty