1306039953 NPI number — DR. LARA L TULL RYAN MS

Table of content: DR. LARA L TULL RYAN MS (NPI 1306039953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306039953 NPI number — DR. LARA L TULL RYAN MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TULL RYAN
Provider First Name:
LARA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TULL
Provider Other First Name:
LARA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306039953
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 W 109TH ST. SUITE 212
Provider Second Line Business Mailing Address:
JOHNSON COUNTY PERIODONTICS
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-491-5548
Provider Business Mailing Address Fax Number:
913-491-0793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4601 W 109TH ST
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
OVERLAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66211-1318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-491-5548
Provider Business Practice Location Address Fax Number:
913-491-0793
Provider Enumeration Date:
08/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  60284 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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