Provider Demographics
NPI:1063571602
Name:LITTLE APPLE PEDIATRIC DENTIST
Entity type:Organization
Organization Name:LITTLE APPLE PEDIATRIC DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-776-7242
Mailing Address - Street 1:1133 COLLEGE AVE
Mailing Address - Street 2:BLDG. D LOWER LEVEL
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2770
Mailing Address - Country:US
Mailing Address - Phone:785-776-7242
Mailing Address - Fax:785-776-5862
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:BLDG. D LOWER LEVEL
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2770
Practice Address - Country:US
Practice Address - Phone:785-776-7242
Practice Address - Fax:785-776-5862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS603851223P0221X
KS53331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty