Provider Demographics
NPI:1346585379
Name:DONALD D. MARDIS, DDS, PA
Entity type:Organization
Organization Name:DONALD D. MARDIS, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MY DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-286-9024
Mailing Address - Street 1:PO BOX 702620
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-2620
Mailing Address - Country:US
Mailing Address - Phone:405-286-9024
Mailing Address - Fax:405-286-9088
Practice Address - Street 1:7450 QUIVIRA RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66216-3526
Practice Address - Country:US
Practice Address - Phone:913-217-7536
Practice Address - Fax:913-766-1019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MY DENTIST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-03
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60859122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty