Provider Demographics
NPI:1821274549
Name:LEGENDS DRIVE DENTAL CENTER LLC
Entity Type:Organization
Organization Name:LEGENDS DRIVE DENTAL CENTER LLC
Other - Org Name:LEGENDS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRITTINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-841-5590
Mailing Address - Street 1:4900 LEGENDS DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3886
Mailing Address - Country:US
Mailing Address - Phone:785-841-5590
Mailing Address - Fax:785-856-2339
Practice Address - Street 1:4900 LEGENDS DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3886
Practice Address - Country:US
Practice Address - Phone:785-841-5590
Practice Address - Fax:785-856-2339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS116786122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty