Healthcare Provider Details

I. General information

NPI: 1861325540
Provider Name (Legal Business Name): ANDREW C SELF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19201 E VALLEY VIEW PKWY STE A
INDEPENDENCE MO
64055-6913
US

IV. Provider business mailing address

19201 E VALLEY VIEW PKWY STE A
INDEPENDENCE MO
64055-6913
US

V. Phone/Fax

Practice location:
  • Phone: 816-478-3600
  • Fax:
Mailing address:
  • Phone: 816-478-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2026023641
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: