Provider Demographics
NPI:1710070008
Name:MOUSE, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MOUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 NE VIVION RD STE 101
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64119-2862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4321 NE VIVION RD STE 101
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64119-2862
Practice Address - Country:US
Practice Address - Phone:816-453-4994
Practice Address - Fax:816-453-5150
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE0126661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice