Provider Demographics
NPI:1336270115
Name:DALLAM, EDWARD D (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:D
Last Name:DALLAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W 95TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66207-3300
Mailing Address - Country:US
Mailing Address - Phone:913-649-0310
Mailing Address - Fax:
Practice Address - Street 1:5000 W 95TH ST STE 300
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66207
Practice Address - Country:US
Practice Address - Phone:913-649-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12689332B00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO06778074OtherBLUE CROSS BLUE SHEILD KC