Healthcare Provider Details

I. General information

NPI: 1851135875
Provider Name (Legal Business Name): ESTHETIC DENTAL IMPLANTS STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19301 E US HIGHWAY 40 STE A
INDEPENDENCE MO
64055-5572
US

IV. Provider business mailing address

19301 E US HIGHWAY 40 STE A
INDEPENDENCE MO
64055-5572
US

V. Phone/Fax

Practice location:
  • Phone: 816-886-5899
  • Fax: 816-873-1938
Mailing address:
  • Phone: 816-886-5899
  • Fax: 816-873-1938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: VENKATA SIVA REDDY GUVVA
Title or Position: OWNER
Credential: BDS
Phone: 419-819-7450