=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700225364
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH MARIE BARRETT DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2013
-----------------------------------------------------
Last Update Date | 01/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 PARK PLAZA DR
-----------------------------------------------------
City | RED BUD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62278-1084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-282-6700
-----------------------------------------------------
Fax | 618-282-6700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 729 WINDING BLUFFS DR
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63026-5564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019.033475
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------