Provider Demographics
NPI:1114028578
Name:KANSAS CITY KANSAS DENTAL ASSOCIATES PA
Entity Type:Organization
Organization Name:KANSAS CITY KANSAS DENTAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-321-4385
Mailing Address - Street 1:753 STATE AVE
Mailing Address - Street 2:STE 665
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66101-2516
Mailing Address - Country:US
Mailing Address - Phone:913-321-4385
Mailing Address - Fax:913-321-4037
Practice Address - Street 1:753 STATE AVE
Practice Address - Street 2:STE 665
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66101-2516
Practice Address - Country:US
Practice Address - Phone:913-321-4385
Practice Address - Fax:913-321-4037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS71281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty