Provider Demographics
NPI:1972080588
Name:GENMAT OP, PA
Entity Type:Organization
Organization Name:GENMAT OP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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:DDS
Authorized Official - Phone:385-215-6097
Mailing Address - Street 1:12180 S 300 E UNIT 270
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-2612
Mailing Address - Country:US
Mailing Address - Phone:913-469-8010
Mailing Address - Fax:
Practice Address - Street 1:11044 QUIVIRA RD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-1239
Practice Address - Country:US
Practice Address - Phone:913-469-8010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61292261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental