Provider Demographics
NPI:1407219017
Name:ELKHART DENTAL LLC
Entity Type:Organization
Organization Name:ELKHART DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:620-792-5523
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:KS
Mailing Address - Zip Code:67950-0068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 S. COSMOS
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:KS
Practice Address - Zip Code:67950
Practice Address - Country:US
Practice Address - Phone:620-697-2253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS604031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty