Healthcare Provider Details

I. General information

NPI: 1356782619
Provider Name (Legal Business Name): BETHANY LACAVERA DHONDT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S ARTHUR ST
HUMANSVILLE MO
65674-8400
US

IV. Provider business mailing address

1500 N OAKLAND AVE
BOLIVAR MO
65613-3011
US

V. Phone/Fax

Practice location:
  • Phone: 417-754-2223
  • Fax: 417-754-8046
Mailing address:
  • Phone: 417-326-6000
  • Fax: 417-326-6936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015008152
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: