Healthcare Provider Details

I. General information

NPI: 1053399022
Provider Name (Legal Business Name): ALAN HOLBROOK BERRY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 CHESTNUT ST
SENECA MO
64865-9261
US

IV. Provider business mailing address

PO BOX 609 1406 CHESTNUT ST
SENECA MO
64865-0609
US

V. Phone/Fax

Practice location:
  • Phone: 417-776-2291
  • Fax: 417-776-2292
Mailing address:
  • Phone: 417-776-2291
  • Fax: 417-776-2292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberMO013033
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: