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NPI Code Detail

MEDICARE: CELEBRACES GLADSTONE FERGUSON DDS LLC

MEDICARE: CELEBRACES GLADSTONE FERGUSON DDS 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
11223X0400XOrthodontics and Dentofacial Orthopedics Dentistry2008028696MO

General Provider Information

NPI Number : 1568904381
Entity Type Code : Organization
Provider Name (Legal Business Name) : CELEBRACES GLADSTONE FERGUSON DDS LLC
Provider Business Mailing Address
First Line : 319 NE VIVION RD
Second Line :
City : KANSAS CITY
State : MO
Zip : 64118-4510
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 319 NE VIVION RD
Second Line :
City : KANSAS CITY
State : MO
Zip : 64118-4510
Country : US
Telephone Number : 210-451-0000
Fax Number :
Authorized Official
Title or Position : OWNER
Name : DAVID B FERGUSON
Credential : DDS, CAGS
Telephone Number : 210-451-0000
Provider Enumeration Date : 11/10/2016
Last Update Date : 01/13/2017

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