Provider Demographics
NPI:1720231848
Name:VOLLERTSEN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:VOLLERTSEN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF DENTAL SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:KURTIS
Authorized Official - Last Name:VOLLERTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:620-275-4251
Mailing Address - Street 1:1402 1/2 E KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-5806
Mailing Address - Country:US
Mailing Address - Phone:620-275-4251
Mailing Address - Fax:620-275-5389
Practice Address - Street 1:1402 1/2 KANSAS AVE.
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846
Practice Address - Country:US
Practice Address - Phone:620-275-4251
Practice Address - Fax:620-275-5389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60401302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2003 857 90 BMedicaid