Provider Demographics
NPI:1235477688
Name:FALES PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:FALES PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KONNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-782-2207
Mailing Address - Street 1:13496 S ARAPAHO DR
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1553
Mailing Address - Country:US
Mailing Address - Phone:913-782-2207
Mailing Address - Fax:913-489-0028
Practice Address - Street 1:13496 S ARAPAHO DR
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1553
Practice Address - Country:US
Practice Address - Phone:913-782-2207
Practice Address - Fax:913-489-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS58591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO405694209Medicaid
KS100222530CMedicaid