Provider Demographics
NPI:1497770200
Name:PERIODONTAL SPECIALIST PA
Entity Type:Organization
Organization Name:PERIODONTAL SPECIALIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:913-663-4867
Mailing Address - Street 1:11401 NALL AVENUE
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1674
Mailing Address - Country:US
Mailing Address - Phone:913-663-4867
Mailing Address - Fax:
Practice Address - Street 1:11401 NALL AVENUE
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1674
Practice Address - Country:US
Practice Address - Phone:913-663-4867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty