Jerad Chance Divine, D.D.S.

Primary specialty

EndodonticsTaxonomy code 1223E0200X

License

61283 Issued in KS

Practice address

12219 E Central Ave
Wichita, KS 67206-2808

Phone

(316) 681-1099

Fax

(316) 613-2417

NPI assigned

Jul 6, 2011

Last updated

Dec 12, 2022By the provider in NPPES

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Previously, effective Sep 11, 2018 through Sep 11, 2026

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Wichita Endodontics LLC

  • Endodontics
  • Wichita, KS
  • NPI 1326564188
  NPD
• Wichita Endodontics LLC

  • Endodontics
  • Witchita, KS
  • NPI 1558949784
  NPD
• Wichita Endodontics LLC

  • Dental Clinic/Center
  • Wichita, KS
  • NPI 1568048809
  NPD (past)

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

{
    "created_epoch": "1309910400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1670803200000",
    "number": "1841587250",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12219 E CENTRAL AVE",
            "city": "WICHITA",
            "state": "KS",
            "postal_code": "672062808",
            "telephone_number": "316-681-1099",
            "fax_number": "316-613-2417"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12219 E CENTRAL AVE",
            "city": "WICHITA",
            "state": "KS",
            "postal_code": "672062808",
            "telephone_number": "316-681-1099",
            "fax_number": "316-613-2417"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DIVINE",
        "first_name": "JERAD",
        "middle_name": "CHANCE",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-07-06",
        "last_updated": "2022-12-12",
        "certification_date": "2022-12-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MO",
            "license": "2011014424",
            "primary": false
        },
        {
            "code": "1223E0200X",
            "taxonomy_group": "",
            "desc": "Dentist, Endodontics",
            "state": "KS",
            "license": "61283",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAL LICENSE",
            "identifier": "2011014424",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Stewart E Dismuke, MD, MPH
• Heather Disney-Black
• Diversified Family Services LLC (LovingTouch Home Health Care)
• Divine Care Homes LLC
• Amanda Gail Divine, NURSE
• Sapana Dixit, RPT
• Candace Nicole Dixon, APRN
• Ceandra Dixon
• Daeauna Dixon
• David Dixon, ARNP

• Endodontics in Wichita, KS
• Providers in Wichita, KS by specialty
• Endodontics in Kansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 12, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.