Basic Information
| Provider Information | |||||||||
| NPI: | 1669858288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RASTGOFTAR | ||||||||
| FirstName: | NADER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 S CLAIRBORNE RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660621774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137303677 | ||||||||
| FaxNumber: | 9137681944 | ||||||||
| Practice Location | |||||||||
| Address1: | 407 S CLAIRBORNE RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660621744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136482266 | ||||||||
| FaxNumber: | 9137681944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2015 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 61222 | KS | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 201130280A | 05 | KS | MEDICAID |