Provider Demographics
NPI:1992195234
Name:BRAISDANALLC
Entity Type:Organization
Organization Name:BRAISDANALLC
Other - Org Name:BEHNAZ RAISDANA, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BEHNAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RAISDANA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:316-304-1582
Mailing Address - Street 1:9509 E SHANNON WAY CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-4042
Mailing Address - Country:US
Mailing Address - Phone:316-304-1582
Mailing Address - Fax:
Practice Address - Street 1:13605 W MAPLE ST
Practice Address - Street 2:SUITE 107 & 109
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-8759
Practice Address - Country:US
Practice Address - Phone:316-304-1582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS610921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty