Provider Demographics
NPI:1174035596
Name:TONGANOXIE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:TONGANOXIE FAMILY DENTISTRY
Other - Org Name:MCLOUTH FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-813-7917
Mailing Address - Street 1:PO BOX 343
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086
Mailing Address - Country:US
Mailing Address - Phone:913-417-7333
Mailing Address - Fax:913-417-7335
Practice Address - Street 1:609 EAST LAKE STREET
Practice Address - Street 2:
Practice Address - City:MCLOUTH
Practice Address - State:KS
Practice Address - Zip Code:66054
Practice Address - Country:US
Practice Address - Phone:913-796-6113
Practice Address - Fax:913-796-6098
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TONGANOXIE FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS608031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty