Provider Demographics
NPI:1497012702
Name:FAMILY DENTISTRY
Entity Type:Organization
Organization Name:FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ELWYN
Authorized Official - Last Name:BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:620-424-4499
Mailing Address - Street 1:113 S MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ULYSSES
Mailing Address - State:KS
Mailing Address - Zip Code:67880-2519
Mailing Address - Country:US
Mailing Address - Phone:620-424-4499
Mailing Address - Fax:620-424-4498
Practice Address - Street 1:113 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:ULYSSES
Practice Address - State:KS
Practice Address - Zip Code:67880-2519
Practice Address - Country:US
Practice Address - Phone:620-424-4499
Practice Address - Fax:620-424-4498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5513261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100225900AMedicaid