Basic Information
| Provider Information | |||||||||
| NPI: | 1295845758 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF KANSAS HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KU DENTAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2330 SHAWNEE MISSION PKWY | ||||||||
| Address2: | MEDICAL ADMINISTRATIVE SERVICES OF KU MED. STE 312 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662052005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135889000 | ||||||||
| FaxNumber: | 9135889822 | ||||||||
| Practice Location | |||||||||
| Address1: | 4720 RAINBOW BLVD | ||||||||
| Address2: | KU DENTAL ASSOCIATES, STE. 250 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662051831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135889200 | ||||||||
| FaxNumber: | 9135889203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | E. | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTIAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9135889000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF KANSAS HOSPITAL AUTHORITY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 452100 | 01 | BCBS KS GROUP NUMBER | OTHER | 36950011 | 01 | BCBS KC GROUP NUMBER | OTHER |