Provider Demographics
NPI:1144325671
Name:PETRIE, KEVIN T (DDS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:PETRIE
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 1:12126 W HUNTERSVIEW ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-1220
Mailing Address - Country:US
Mailing Address - Phone:316-721-6989
Mailing Address - Fax:
Practice Address - Street 1:3455 W 13TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-4500
Practice Address - Country:US
Practice Address - Phone:316-945-0543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS57631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS10022250AMedicaid
KS7849OtherBCBS ID