Provider Demographics
NPI:1144495169
Name:WICHITA STATE UNIVERSITY
Entity type:Organization
Organization Name:WICHITA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRPERSON
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-978-3614
Mailing Address - Street 1:12105 NANTUCKET ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-1224
Mailing Address - Country:US
Mailing Address - Phone:316-721-9885
Mailing Address - Fax:
Practice Address - Street 1:1845 FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67260-9700
Practice Address - Country:US
Practice Address - Phone:316-978-3614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty