Provider Demographics
NPI:1053048116
Name:FRY, TIARA ARIANNE (DDS)
Entity type:Individual
Prefix:DR
First Name:TIARA
Middle Name:ARIANNE
Last Name:FRY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8961 METCALF AVE APT 424
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-1500
Mailing Address - Country:US
Mailing Address - Phone:314-749-2238
Mailing Address - Fax:
Practice Address - Street 1:10818 PARALLEL PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109-3649
Practice Address - Country:US
Practice Address - Phone:913-299-8860
Practice Address - Fax:913-299-8880
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220192871223G0001X
KS620111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1053048116Medicaid