Provider Demographics
NPI:1568048809
Name:WICHITA ENDODONTICS LLC
Entity Type:Organization
Organization Name:WICHITA ENDODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-681-1099
Mailing Address - Street 1:7721 W. 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1737
Mailing Address - Country:US
Mailing Address - Phone:316-681-1099
Mailing Address - Fax:316-613-2417
Practice Address - Street 1:7721 W 21ST ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205
Practice Address - Country:US
Practice Address - Phone:316-681-1099
Practice Address - Fax:316-613-2417
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WICHITA ENDODONTICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental