Provider Demographics
NPI:1538469671
Name:MOUNDRIDGE DENTAL CENTER CHARTERED
Entity Type:Organization
Organization Name:MOUNDRIDGE DENTAL CENTER CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:HILDRETH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-456-7083
Mailing Address - Street 1:5566 MAEFIELD DR STE B
Mailing Address - Street 2:
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547-9109
Mailing Address - Country:US
Mailing Address - Phone:785-456-7083
Mailing Address - Fax:785-456-6520
Practice Address - Street 1:324 E 2ND ST
Practice Address - Street 2:
Practice Address - City:MOUNDRIDGE
Practice Address - State:KS
Practice Address - Zip Code:67107-7164
Practice Address - Country:US
Practice Address - Phone:620-345-2100
Practice Address - Fax:620-345-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS607281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty