Provider Demographics
NPI:1811011018
Name:PEDIATRIC DENTAL SPECIALISTS, PA
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-525-5447
Mailing Address - Street 1:3355 NE RALPH POWELL ROAD
Mailing Address - Street 2:
Mailing Address - City:LEE'S SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064
Mailing Address - Country:US
Mailing Address - Phone:816-525-5447
Mailing Address - Fax:
Practice Address - Street 1:3355 NE RALPH POWELL ROAD
Practice Address - Street 2:
Practice Address - City:LEE'S SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064
Practice Address - Country:US
Practice Address - Phone:816-525-5447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015672261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental