Healthcare Provider Details

I. General information

NPI: 1023338860
Provider Name (Legal Business Name): COURTNEY LEIGH BEUSSINK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N 1ST ST
MARBLE HILL MO
63764
US

IV. Provider business mailing address

103 N 1ST ST
MARBLE HILL MO
63764
US

V. Phone/Fax

Practice location:
  • Phone: 573-238-3330
  • Fax: 573-238-3464
Mailing address:
  • Phone: 573-238-3330
  • Fax: 573-238-3464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2010016160
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: