Provider Demographics
NPI:1609395342
Name:WHEAT STATE DENTAL, LLC
Entity Type:Organization
Organization Name:WHEAT STATE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:DEWITTE
Authorized Official - Last Name:ROSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:913-687-5353
Mailing Address - Street 1:11150 S. PFLUMM RD
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66215-3506
Mailing Address - Country:US
Mailing Address - Phone:913-782-0674
Mailing Address - Fax:913-469-5104
Practice Address - Street 1:11150 S. PFLUMM RD
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-3506
Practice Address - Country:US
Practice Address - Phone:913-782-0674
Practice Address - Fax:913-469-5104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental