Provider Demographics
NPI:1619354545
Name:EDWARDS & WILSON PERIODONTICS OF TOPEKA, LLC
Entity Type:Organization
Organization Name:EDWARDS & WILSON PERIODONTICS OF TOPEKA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLI
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-272-0770
Mailing Address - Street 1:3033 SW VILLA WEST DR STE B
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-4488
Mailing Address - Country:US
Mailing Address - Phone:785-272-0770
Mailing Address - Fax:785-272-0035
Practice Address - Street 1:3033 SW VILLA WEST DR STE B
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-4488
Practice Address - Country:US
Practice Address - Phone:785-272-0770
Practice Address - Fax:785-272-0035
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDWARDS AND WILSON PERIODONTICS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6357122300000X
KS60071122300000X
KS61063122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS7948912OtherBUSINESS ENTITY ID NUMBER