Provider Demographics
NPI:1972740843
Name:REFLECTION RIDGE DENTAL, LLC
Entity Type:Organization
Organization Name:REFLECTION RIDGE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:316-721-2024
Mailing Address - Street 1:7570 W 21ST ST N
Mailing Address - Street 2:1050B
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1734
Mailing Address - Country:US
Mailing Address - Phone:316-721-2024
Mailing Address - Fax:316-721-9189
Practice Address - Street 1:7570 W 21ST ST N
Practice Address - Street 2:1050B
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1734
Practice Address - Country:US
Practice Address - Phone:316-721-2024
Practice Address - Fax:316-721-9189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5688305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1891774535OtherNPI OF DR DOLD