MEDICARE: DR. KEVIN RUSSELL DUNIVEN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2012015445	MO

General Provider Information

NPI Number	:	1316207475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN RUSSELL DUNIVEN D.D.S.

Provider Business Mailing Address
First Line	:	11426 GRAVOIS RD
Second Line	:	SUITE 202
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-3656
Country	:	US
Telephone Number	:	314-962-1574
Fax Number	:	314-962-8585

Provider Business Practice Location Address
First Line	:	11426 GRAVOIS RD
Second Line	:	SUITE 202
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-3656
Country	:	US
Telephone Number	:	314-962-1574
Fax Number	:	314-962-8585

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2012
Last Update Date	:	10/12/2015

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