MEDICARE: ASSOCIATED PEDIATRIC DENTISTRY LTD

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		IL

General Provider Information

NPI Number	:	1952497901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASSOCIATED PEDIATRIC DENTISTRY LTD

Provider Business Mailing Address
First Line	:	4945 STONE FALLS CTR
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 CTR
Second Line	:	SUITE 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	:	OWNER DENTIST
Name	:	KEVIN CHARLES BEYERSDORFER
Credential	:	DDS
Telephone Number	:	618-622-0212

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	07/21/2022

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Directions to “ASSOCIATED PEDIATRIC DENTISTRY LTD ” Practice Location

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