Provider Demographics
NPI:1679041644
Name:TINY TEETH PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:TINY TEETH PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HEALY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:913-220-8907
Mailing Address - Street 1:3933 N MAIZE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MAIZE
Mailing Address - State:KS
Mailing Address - Zip Code:67101-9619
Mailing Address - Country:US
Mailing Address - Phone:316-202-0140
Mailing Address - Fax:316-204-0141
Practice Address - Street 1:3933 N. MAIZE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-6710
Practice Address - Country:US
Practice Address - Phone:316-202-0140
Practice Address - Fax:316-202-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty