Provider Demographics
NPI:1205208568
Name:HILLSIDE FAMILY DENTIST, PA
Entity type:Organization
Organization Name:HILLSIDE FAMILY DENTIST, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GUEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-645-0079
Mailing Address - Street 1:1648 S OHIO ST
Mailing Address - Street 2:SUITE #259
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-6360
Mailing Address - Country:US
Mailing Address - Phone:913-645-0079
Mailing Address - Fax:
Practice Address - Street 1:841 S HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-3005
Practice Address - Country:US
Practice Address - Phone:316-681-1530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty