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General NPI Number Information
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NPI Number | 1427660018
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Entity Type | Organization
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Legal Business Name | EASTRIDGE FAMILY DENTAL, PC
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Dates
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Enumeration Date | 08/17/2020
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Last Update Date | 02/05/2024
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Provider Practice Location Address
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Address Line | 325 SE WILSON ST
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City | LEES SUMMIT
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State | MO
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Zip | 64063-2715
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Country | US
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Telephone | 816-525-0399
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Fax |
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Provider Business Mailing Address
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Address Line | 325 SE WILSON ST
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City | LEES SUMMIT
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State | MO
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Zip | 64063-2715
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Country | US
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Telephone | 816-525-0399
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRAD NELSON
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Credential |
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Telephone | 405-260-6080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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