Provider Demographics
NPI:1194365817
Name:WICHITA FAMILY DENTAL SOUTH LLC
Entity Type:Organization
Organization Name:WICHITA FAMILY DENTAL SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRANDES
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:316-630-9339
Mailing Address - Street 1:9339 E 21ST ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2971
Mailing Address - Country:US
Mailing Address - Phone:316-630-9339
Mailing Address - Fax:
Practice Address - Street 1:1120 N ROCK RD STE 100
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3587
Practice Address - Country:US
Practice Address - Phone:316-630-9339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental