Provider Demographics
NPI:1376744862
Name:ELDER, KATHLEEN M (RDH, OM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:ELDER
Suffix:
Gender:F
Credentials:RDH, OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12882 S WIDMER ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-8800
Mailing Address - Country:US
Mailing Address - Phone:913-764-9108
Mailing Address - Fax:913-397-6513
Practice Address - Street 1:975 N MUR LEN RD
Practice Address - Street 2:#C
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1861
Practice Address - Country:US
Practice Address - Phone:913-829-4466
Practice Address - Fax:913-829-0187
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
124Q00000X
KS145-C-08174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS20-1580627OtherTAX EIN #