NPIMap

Organization Active NPI

Country Club Dental PA

  • General Practice Dentistry
  • Topeka, KS
National Provider Identifier
1699137109
Registry record updated Sep 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
COUNTRY CLUB DENTAL PA
Practice address
400 SW 29TH St
Suite M
Topeka, KS 66611-1164
Phone
(785) 783-5981
Fax
(785) 783-5982
NPI assigned
Mar 23, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 9, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shaun Urbanozo
Title
Credentialing Manager
Phone
(719) 323-2362

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223G0001X
General Practice DentistryGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223G0001X KS Primary

Addresses

Primary practice location

400 SW 29TH St
Suite M
Topeka, KS 66611-1164

Mailing address

2221 E Bijou St
Ste 100
Colorado Springs, CO 80909-8009
Phone (719) 576-1850

Other identifiers 1

IdentifierTypeStateIssuer
201199030AMedicaidKS

Other names 1

  • Adventure Dental and Vision Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1458691200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757376000000",
    "number": "1699137109",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2221 E BIJOU ST",
            "address_2": "STE 100",
            "city": "COLORADO SPRINGS",
            "state": "CO",
            "postal_code": "809098009",
            "telephone_number": "719-576-1850",
            "fax_number": "719-955-3470"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 SW 29TH ST",
            "address_2": "SUITE M",
            "city": "TOPEKA",
            "state": "KS",
            "postal_code": "666111164",
            "telephone_number": "785-783-5981",
            "fax_number": "785-783-5982"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY CLUB DENTAL PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-03-23",
        "last_updated": "2025-09-09",
        "certification_date": "2025-09-09",
        "status": "A",
        "authorized_official_last_name": "URBANOZO",
        "authorized_official_first_name": "SHAUN",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "719-323-2362"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "KS",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201199030A",
            "state": "KS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Adventure Dental and Vision",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Adventure Dental and Vision",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Topeka, KS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.