Provider Demographics
NPI:1528310331
Name:WICHITA DENTAL GROUP PA
Entity type:Organization
Organization Name:WICHITA DENTAL GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:316-265-0849
Mailing Address - Street 1:301 N MAIN ST
Mailing Address - Street 2:SUITE 1420
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-4800
Mailing Address - Country:US
Mailing Address - Phone:316-265-0849
Mailing Address - Fax:316-265-6307
Practice Address - Street 1:301 N MAIN ST
Practice Address - Street 2:SUITE 1420
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-4800
Practice Address - Country:US
Practice Address - Phone:316-265-0849
Practice Address - Fax:316-265-6307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6445122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty