Provider Demographics
NPI:1730116237
Name:NOSSAMAN, JERRY R (DDS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:R
Last Name:NOSSAMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 WEST HILLS PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044
Mailing Address - Country:US
Mailing Address - Phone:785-842-7181
Mailing Address - Fax:785-843-4335
Practice Address - Street 1:831 VERMONT ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2665
Practice Address - Country:US
Practice Address - Phone:785-843-6060
Practice Address - Fax:785-843-4335
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4549122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS36600015OtherBCBS OF KC
KS116938OtherBCBS OF KS