Provider Demographics
NPI:1114106739
Name:S KIRK VINCENT D.D.S., L.C.
Entity Type:Organization
Organization Name:S KIRK VINCENT D.D.S., L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-841-2902
Mailing Address - Street 1:4811 BOB BILLINGS PARKWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049
Mailing Address - Country:US
Mailing Address - Phone:785-841-2902
Mailing Address - Fax:785-841-5312
Practice Address - Street 1:4811 BOB BILLINGS PARKWAY
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049
Practice Address - Country:US
Practice Address - Phone:785-841-2902
Practice Address - Fax:785-841-5312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS63621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
420714OtherPTAN
116521VIMedicare PIN
KST44089Medicare UPIN