Provider Demographics
NPI:1871948497
Name:STTT DENTAL SERVICES LLC CORP
Entity type:Organization
Organization Name:STTT DENTAL SERVICES LLC CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SHAWHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:620-725-3122
Mailing Address - Street 1:120 W OSAGE ST
Mailing Address - Street 2:
Mailing Address - City:SEDAN
Mailing Address - State:KS
Mailing Address - Zip Code:67361-1518
Mailing Address - Country:US
Mailing Address - Phone:620-725-3122
Mailing Address - Fax:620-725-5395
Practice Address - Street 1:120 W OSAGE ST
Practice Address - Street 2:
Practice Address - City:SEDAN
Practice Address - State:KS
Practice Address - Zip Code:67361-1518
Practice Address - Country:US
Practice Address - Phone:620-725-3122
Practice Address - Fax:620-725-5395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
KS61288305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201126710AMedicaid