Provider Demographics
NPI:1063099943
Name:COTTONWOOD DENTAL KELLOGG, P.A.
Entity type:Organization
Organization Name:COTTONWOOD DENTAL KELLOGG, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-998-0996
Mailing Address - Street 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:918-310-1056
Practice Address - Street 1:11333 E KELLOGG DR STE 900
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-1960
Practice Address - Country:US
Practice Address - Phone:918-998-0996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental