=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922401397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARON DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2014
-----------------------------------------------------
Last Update Date | 09/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1170 W KANSAS ST SUITE R-2
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-2036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-716-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1170 W KANSAS ST SUITE R-2
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-2036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-716-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BARON GRUTTER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 816-716-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2010016293
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------