Provider Demographics
NPI:1770899205
Name:MISSURA, LUIS FERNANDO (DMD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:MISSURA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-4512
Mailing Address - Country:US
Mailing Address - Phone:913-346-3636
Mailing Address - Fax:913-346-3636
Practice Address - Street 1:2541 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-4512
Practice Address - Country:US
Practice Address - Phone:913-346-3636
Practice Address - Fax:913-346-3636
Is Sole Proprietor?:No
Enumeration Date:2010-08-21
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10235122300000X
CODEN.000102351223E0200X
KS615011223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist