MEDICARE: PEDS, LLC

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	1223P0221X	Pediatric Dentistry	2014012737	MO

General Provider Information

NPI Number	:	1336548106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDS, LLC

Provider Business Mailing Address
First Line	:	4741 CENTRAL ST
Second Line	:	SUITE #107
City	:	KANSAS CITY
State	:	MO
Zip	:	64112-1533
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4741 CENTRAL ST
Second Line	:	SUITE #107
City	:	KANSAS CITY
State	:	MO
Zip	:	64112-1533
Country	:	US
Telephone Number	:	402-972-7751
Fax Number	:

Authorized Official
Title or Position	:	ORGANIZER
Name	:	DR. MATTHEW DAVID ANDERSON
Credential	:	D.D.S.
Telephone Number	:	402-972-7751

Provider Enumeration Date	:	08/18/2014
Last Update Date	:	08/18/2014

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