Provider Demographics
NPI:1992865612
Name:CAROL M. YSIDRO, D.D.S.,P.A.
Entity Type:Organization
Organization Name:CAROL M. YSIDRO, D.D.S.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:
Authorized Official - Last Name:YSIDRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-788-2118
Mailing Address - Street 1:PO BOX 1258
Mailing Address - Street 2:900 E. MEADOWLARK
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-5258
Mailing Address - Country:US
Mailing Address - Phone:316-788-2118
Mailing Address - Fax:316-789-9098
Practice Address - Street 1:900 E. MEADOWLARK
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-5258
Practice Address - Country:US
Practice Address - Phone:316-788-2118
Practice Address - Fax:316-789-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS600241223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty