Provider Demographics
NPI:1295998144
Name:SHOAL CREEK PEDIATRIC DENTISTRY, L.L.C.
Entity type:Organization
Organization Name:SHOAL CREEK PEDIATRIC DENTISTRY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-781-5437
Mailing Address - Street 1:9051 NE 81ST TERRACE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64158
Mailing Address - Country:US
Mailing Address - Phone:816-781-5437
Mailing Address - Fax:
Practice Address - Street 1:9051 NE 81ST TERRACE
Practice Address - Street 2:SUITE 220
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64158
Practice Address - Country:US
Practice Address - Phone:816-781-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050342071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty