Provider Demographics
NPI:1487751509
Name:CEDAR LODGE DENTAL CENTER
Entity type:Organization
Organization Name:CEDAR LODGE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-625-7369
Mailing Address - Street 1:1001 CODY AVE
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2430
Mailing Address - Country:US
Mailing Address - Phone:785-625-7369
Mailing Address - Fax:785-625-7667
Practice Address - Street 1:1001 CODY AVE
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2430
Practice Address - Country:US
Practice Address - Phone:785-625-7369
Practice Address - Fax:785-625-7667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5950122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA835408OtherUNITED CONCORDIA DENTAL
KS59703OtherBCBS KS INSURANCE