Provider Demographics
NPI:1356495394
Name:MADJARAC, KEVIN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:MADJARAC
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 BENT OAK CT
Mailing Address - Street 2:
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-7625
Mailing Address - Country:US
Mailing Address - Phone:785-239-7241
Mailing Address - Fax:785-239-7245
Practice Address - Street 1:520 POPE AVENUE
Practice Address - Street 2:US ARMY DENTAL ACTIVITY
Practice Address - City:FT. LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027
Practice Address - Country:US
Practice Address - Phone:785-239-7241
Practice Address - Fax:785-239-7245
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021957122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist