Provider Demographics
NPI:1407047152
Name:MAYUGA, ERIC J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:J
Last Name:MAYUGA
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:PO BOX 271
Mailing Address - Street 2:204 E MAIN ST
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030
Mailing Address - Country:US
Mailing Address - Phone:913-856-6171
Mailing Address - Fax:913-884-6151
Practice Address - Street 1:204 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:KS
Practice Address - Zip Code:66030
Practice Address - Country:US
Practice Address - Phone:913-856-6171
Practice Address - Fax:913-884-6151
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS70311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO23931023OtherBCBS OF KC
KS383059OtherBCBS OF KS