Provider Demographics
NPI:1164459822
Name:MCQUILLEN, JOHN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:MCQUILLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:MCQUILLEN
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1700 COMMERCIAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547
Mailing Address - Country:US
Mailing Address - Phone:785-456-9393
Mailing Address - Fax:785-456-6650
Practice Address - Street 1:1700 COMMERCIAL CIRCLE
Practice Address - Street 2:
Practice Address - City:WAMEGO
Practice Address - State:KS
Practice Address - Zip Code:66547
Practice Address - Country:US
Practice Address - Phone:785-456-9393
Practice Address - Fax:785-456-6650
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS64881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1002240606CMedicaid