Provider Demographics
NPI:1831945443
Name:AMECHI, BLOSSOM
Entity type:Individual
Prefix:
First Name:BLOSSOM
Middle Name:
Last Name:AMECHI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10333 E 21ST ST N STE 101
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3544
Mailing Address - Country:US
Mailing Address - Phone:316-684-1470
Mailing Address - Fax:
Practice Address - Street 1:10333 E 21ST ST N STE 101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3544
Practice Address - Country:US
Practice Address - Phone:316-684-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS1000X
KS62240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health