Provider Demographics
NPI:1558781419
Name:DONALD D. MARDIS, DDS, PA
Entity Type:Organization
Organization Name:DONALD D. MARDIS, DDS, PA
Other - Org Name:QUIVIRA DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8468
Mailing Address - Street 1:7450 QUIVIRA RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66216-3526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7450 QUIVIRA RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66216-3526
Practice Address - Country:US
Practice Address - Phone:913-217-7536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DONALD D. MARDIS, DDS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-18
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty