Provider Demographics
NPI:1477632560
Name:CHARLES L. KINCAID D.D.S. P.A.
Entity Type:Organization
Organization Name:CHARLES L. KINCAID D.D.S. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:KINCAID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-843-4333
Mailing Address - Street 1:306 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66046-4801
Mailing Address - Country:US
Mailing Address - Phone:785-843-4333
Mailing Address - Fax:785-843-1218
Practice Address - Street 1:306 E 23RD ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66046-4801
Practice Address - Country:US
Practice Address - Phone:785-843-4333
Practice Address - Fax:785-843-1218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100096960BMedicaid
KS100348570BMedicaid