1811036247 NPI number — MRS. TYESHA DAWN MARIE DENT PA-C

Table of content: MRS. TYESHA DAWN MARIE DENT PA-C (NPI 1811036247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811036247 NPI number — MRS. TYESHA DAWN MARIE DENT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENT
Provider First Name:
TYESHA
Provider Middle Name:
DAWN MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SITSLER
Provider Other First Name:
TYESHA
Provider Other Middle Name:
DAWN MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811036247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19680 BLUE JAY TRAIL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWSON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64062-7032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-209-0350
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10015 N AMBASSADOR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64153-1364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-595-4000
Provider Business Practice Location Address Fax Number:
701-584-3011
Provider Enumeration Date:
02/05/2007

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: 363A00000X , with the licence number:  2021036928 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11228 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28537 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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