MEDICARE: DALE DAVID LAIRD M.D.

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	207W00000X	Ophthalmology Physician	R4200	MO

General Provider Information

NPI Number	:	1790073450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALE DAVID LAIRD M.D.

Provider Business Mailing Address
First Line	:	30 HEVER KNOLL
Second Line	:
City	:	LOCH LLOYD
State	:	MO
Zip	:	64012
Country	:	US
Telephone Number	:	816-322-1052
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 HEVER KNOLL
Second Line	:
City	:	LOCH LLOYD
State	:	MO
Zip	:	64012
Country	:	US
Telephone Number	:	816-322-1052
Fax Number	:

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

Provider Enumeration Date	:	07/15/2011
Last Update Date	:	07/15/2011

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