Basic Information
Provider Information | |||||||||
NPI: | 1700990579 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRYAN K. DENNETT, M.D., P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1305 E 19TH AVE | ||||||||
Address2: |   | ||||||||
City: | WINFIELD | ||||||||
State: | KS | ||||||||
PostalCode: | 671565201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202219500 | ||||||||
FaxNumber: | 6202214020 | ||||||||
Practice Location | |||||||||
Address1: | 1305 E 19TH AVE | ||||||||
Address2: |   | ||||||||
City: | WINFIELD | ||||||||
State: | KS | ||||||||
PostalCode: | 671565201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202219500 | ||||||||
FaxNumber: | 6202214020 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2006 | ||||||||
LastUpdateDate: | 08/29/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DENNETT | ||||||||
AuthorizedOfficialFirstName: | BRYAN | ||||||||
AuthorizedOfficialMiddleName: | K. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6202219500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4027010 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100298390D | 05 | KS |   | MEDICAID | 665220 | 01 | KS | FIRSTGUARD INSURANCE | OTHER | 110819 | 01 | KS | BC/BS OF KANSAS | OTHER |