Provider Demographics
NPI:1861846420
Name:CENTRAL AVE DENTAL LLC
Entity Type:Organization
Organization Name:CENTRAL AVE DENTAL LLC
Other - Org Name:CENTRAL AVE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:H
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-342-5280
Mailing Address - Street 1:1320 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66102-5030
Mailing Address - Country:US
Mailing Address - Phone:913-342-5280
Mailing Address - Fax:816-533-7170
Practice Address - Street 1:1320 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-5030
Practice Address - Country:US
Practice Address - Phone:913-342-5280
Practice Address - Fax:816-533-7170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS612921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty