Provider Demographics
NPI:1245370345
Name:KIDSPACE PEDIATRIC DENTISTRY,P.A
Entity type:Organization
Organization Name:KIDSPACE PEDIATRIC DENTISTRY,P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-684-2100
Mailing Address - Street 1:430 N WOODLAWN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-4334
Mailing Address - Country:US
Mailing Address - Phone:316-684-2100
Mailing Address - Fax:316-684-2101
Practice Address - Street 1:430 N WOODLAWN ST STE 1
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4334
Practice Address - Country:US
Practice Address - Phone:316-684-2100
Practice Address - Fax:316-684-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS65221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty