Healthcare Provider Details

I. General information

NPI: 1023234531
Provider Name (Legal Business Name): GERARD R FELDHAUS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E 69 HIGHWAY
CLAYCOMO MO
64119
US

IV. Provider business mailing address

711 WESTWOODS DRIVE
LIBERTY MO
64068-3459
US

V. Phone/Fax

Practice location:
  • Phone: 816-454-0377
  • Fax: 816-454-9996
Mailing address:
  • Phone: 816-792-2372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberMO13663
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: