Provider Demographics
NPI:1790940872
Name:ANTIOCH DENTAL INC
Entity Type:Organization
Organization Name:ANTIOCH DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRWIN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BOE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:913-642-0031
Mailing Address - Street 1:8650 W 95TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-3246
Mailing Address - Country:US
Mailing Address - Phone:913-642-0031
Mailing Address - Fax:913-642-2188
Practice Address - Street 1:8650 W 95TH ST STE 2
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-3246
Practice Address - Country:US
Practice Address - Phone:913-642-0031
Practice Address - Fax:913-642-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60303122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty