MEDICARE: ADVANCED DENTISTRY OF NEVADA

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1912674466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DENTISTRY OF NEVADA

Provider Business Mailing Address
First Line	:	1701 W AUSTIN BLVD
Second Line	:
City	:	NEVADA
State	:	MO
Zip	:	64772-3720
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 W AUSTIN BLVD
Second Line	:
City	:	NEVADA
State	:	MO
Zip	:	64772-3720
Country	:	US
Telephone Number	:	417-667-7134
Fax Number	:

Authorized Official
Title or Position	:	SOLE MBR
Name	:	DR. TREY K KALBAUGH
Credential	:
Telephone Number	:	417-393-8613

Provider Enumeration Date	:	08/24/2021
Last Update Date	:	09/06/2023

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1629885942 — BRITTNEY BAISDEN MA, PPS
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Directions to “ADVANCED DENTISTRY OF NEVADA ” Practice Location

Language	Start Address	Practice Location

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