Provider Demographics
NPI:1992176531
Name:GREAT PLAINS DENTAL GROUP, LLC
Entity type:Organization
Organization Name:GREAT PLAINS DENTAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-916-5036
Mailing Address - Street 1:650 N CARRIAGE PKWY
Mailing Address - Street 2:#60
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-4507
Mailing Address - Country:US
Mailing Address - Phone:316-686-2721
Mailing Address - Fax:316-395-1233
Practice Address - Street 1:650 N CARRIAGE PKWY
Practice Address - Street 2:#60
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208
Practice Address - Country:US
Practice Address - Phone:316-686-2721
Practice Address - Fax:316-395-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty