Provider Demographics
NPI:1336427582
Name:WICHITA STATE UNIVERSITY
Entity Type:Organization
Organization Name:WICHITA STATE UNIVERSITY
Other - Org Name:ADVANCED EDUCATION IN GENERAL DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JO
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:CLEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:316-978-5662
Mailing Address - Street 1:1845 FAIRMOUNT ST
Mailing Address - Street 2:BOX 157
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67260-0043
Mailing Address - Country:US
Mailing Address - Phone:316-978-5662
Mailing Address - Fax:316-978-3025
Practice Address - Street 1:2838 N. OLIVER
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-0157
Practice Address - Country:US
Practice Address - Phone:316-978-5662
Practice Address - Fax:316-978-3025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WICHITA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty