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General NPI Number Information
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NPI Number | 1962037523
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Entity Type | Organization
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Legal Business Name | BEVERLY MOON DMD LLC
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Dates
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Enumeration Date | 03/04/2020
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Last Update Date | 03/04/2020
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Provider Practice Location Address
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Address Line | 4601 W 109TH ST STE 240
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City | OVERLAND PARK
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State | KS
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Zip | 66211-1323
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Country | US
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Telephone | 913-338-3384
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Fax |
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Provider Business Mailing Address
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Address Line | 16424 LUCILLE ST
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City | OVERLAND PARK
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State | KS
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Zip | 66221-7032
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Country | US
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Telephone | 732-754-1998
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | BEVERLY MOON
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Credential | DMD
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Telephone | 732-754-1998
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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