Provider Demographics
NPI:1851526693
Name:KC DENTAL PROFESSIONALS, PA
Entity Type:Organization
Organization Name:KC DENTAL PROFESSIONALS, PA
Other - Org Name:DEER CREEK FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:13328 METCALF AVE
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13328 METCALF AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-2804
Practice Address - Country:US
Practice Address - Phone:913-345-2273
Practice Address - Fax:913-345-8102
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KC DENTAL PROFESSIONALS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-22
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty