Provider Demographics
NPI:1578750196
Name:KAW PC
Entity Type:Organization
Organization Name:KAW PC
Other - Org Name:CHANDLER FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILGUESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-258-2684
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834
Mailing Address - Country:US
Mailing Address - Phone:405-258-2684
Mailing Address - Fax:405-258-5353
Practice Address - Street 1:1516 S IOWA
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834
Practice Address - Country:US
Practice Address - Phone:405-258-2684
Practice Address - Fax:405-258-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54871223G0001X
OK55031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK310784561002OtherBLUE CROSS BLUE SHIELD
OK01307512OtherUNITED CONCORDIA
OK445862194001OtherBLUE CROSS BLUE SHIELD