Provider Demographics
NPI:1417222993
Name:MIDWEST DENTAL KANSAS DERBY PA
Entity Type:Organization
Organization Name:MIDWEST DENTAL KANSAS DERBY PA
Other - Org Name:MIDWEST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-291-9542
Mailing Address - Street 1:1700 E JAMES ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3543
Mailing Address - Country:US
Mailing Address - Phone:316-788-3736
Mailing Address - Fax:316-788-4158
Practice Address - Street 1:1700 E JAMES ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3543
Practice Address - Country:US
Practice Address - Phone:316-788-3736
Practice Address - Fax:316-788-4158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty