Provider Demographics
NPI:1225144256
Name:PROSE, RENATA L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RENATA
Middle Name:L
Last Name:PROSE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:RENATA
Other - Middle Name:L
Other - Last Name:LICHTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MCPHERSON
Mailing Address - State:KS
Mailing Address - Zip Code:67460
Mailing Address - Country:US
Mailing Address - Phone:620-241-6512
Mailing Address - Fax:
Practice Address - Street 1:801 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460
Practice Address - Country:US
Practice Address - Phone:620-241-6512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9879122300000X
OH30-0223831223G0001X
KSKS606891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist