Provider Demographics
NPI:1942795976
Name:BLUE VALLEY PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:BLUE VALLEY PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:AXELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:913-232-2708
Mailing Address - Street 1:7560 W 160TH STREET
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66085
Mailing Address - Country:US
Mailing Address - Phone:913-232-2708
Mailing Address - Fax:503-232-2718
Practice Address - Street 1:7560 W 160TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66085
Practice Address - Country:US
Practice Address - Phone:913-232-2708
Practice Address - Fax:913-232-2718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty