MEDICARE: KEVIN CHARLES BEYERSDORFER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	019021773	IL

General Provider Information

NPI Number	:	1295814002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN CHARLES BEYERSDORFER DDS

Provider Business Mailing Address
First Line	:	4945 STONE FALLS CENTER
Second Line	:	SUITE B
City	:	O FALLON
State	:	IL
Zip	:	62269-7802
Country	:	US
Telephone Number	:	618-622-0212
Fax Number	:	618-622-1996

Provider Business Practice Location Address
First Line	:	4945 STONE FALLS CENTER
Second Line	:	STE B
City	:	O FALLON
State	:	IL
Zip	:	62269-7802
Country	:	US
Telephone Number	:	618-622-0212
Fax Number	:	618-622-1996

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	06/11/2008

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