Provider First Line Business Practice Location Address:
4100 W MAPLE ST
Provider Second Line Business Practice Location Address:
C/O FAMILY DENTISTRY & PREVENTIVE CARE BUILDING
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67209-2538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-530-3191
Provider Business Practice Location Address Fax Number:
316-854-0821
Provider Enumeration Date:
01/28/2014