Provider Demographics
NPI:1487869046
Name:GABRIEL WURDEMAN
Entity type:Organization
Organization Name:GABRIEL WURDEMAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
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:2007-05-14
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS603911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200380810AMedicaid