Provider Demographics
NPI:1427024868
Name:SMALL SMILES OF WICHITA, LLC
Entity Type:Organization
Organization Name:SMALL SMILES OF WICHITA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, LICENSING & CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-686-2721
Mailing Address - Street 1:650 N CARRIAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-4507
Mailing Address - Country:US
Mailing Address - Phone:316-686-2721
Mailing Address - Fax:316-686-2744
Practice Address - Street 1:650 N CARRIAGE PKWY
Practice Address - Street 2:SUITE #60
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4507
Practice Address - Country:US
Practice Address - Phone:316-686-2721
Practice Address - Fax:316-686-2744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200383480AMedicaid