Provider Demographics
NPI:1396734737
Name:DOUGLAS COUNTY DENTAL CLINIC, INC
Entity type:Organization
Organization Name:DOUGLAS COUNTY DENTAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:MEREDITH
Authorized Official - Last Name:BRANSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-312-7770
Mailing Address - Street 1:2210 YALE RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-2647
Mailing Address - Country:US
Mailing Address - Phone:785-312-7770
Mailing Address - Fax:785-312-9447
Practice Address - Street 1:2210 YALE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-2647
Practice Address - Country:US
Practice Address - Phone:785-312-7770
Practice Address - Fax:785-312-9447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS602181223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103395Medicaid
KS100414900AMedicaid