Provider Demographics
NPI:1902378722
Name:ETHERIDGE COMPLETE DENTISTRY LLC
Entity Type:Organization
Organization Name:ETHERIDGE COMPLETE DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-525-1655
Mailing Address - Street 1:818 NW PARK LN
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-1880
Mailing Address - Country:US
Mailing Address - Phone:816-525-1655
Mailing Address - Fax:816-524-7800
Practice Address - Street 1:818 NW PARK LN
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-1880
Practice Address - Country:US
Practice Address - Phone:816-525-1655
Practice Address - Fax:816-524-7800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty