Provider Demographics
NPI:1144207705
Name:THE INDIAN SPRINGS DENTAL CLINIC, LLC
Entity Type:Organization
Organization Name:THE INDIAN SPRINGS DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, LICENSING & CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-287-7977
Mailing Address - Street 1:4655 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66102-3601
Mailing Address - Country:US
Mailing Address - Phone:913-287-7977
Mailing Address - Fax:913-287-5022
Practice Address - Street 1:4655 STATE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-3603
Practice Address - Country:US
Practice Address - Phone:913-287-7977
Practice Address - Fax:913-287-5022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1144207705Medicaid
KS200383490AMedicaid