Individual
DR. JERAD CHANCE DIVINE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
12219 E CENTRAL AVE, WICHITA, KS 67206-2808
(316) 681-1099
(316) 613-2417
Mailing address
12219 E CENTRAL AVE, WICHITA, KS 67206-2808
(316) 681-1099
(316) 613-2417
Taxonomy
Speciality
Code
Description
License number
State
1223E0200X
Endodontics
Primary
61283
KS
1223G0001X
General Practice Dentistry
2011014424
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2011014424
DENTAL LICENSE
MO
Enumeration date
07/06/2011
Last updated
12/12/2022
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