Provider Demographics
NPI:1033420039
Name:BERRY, MEAGAN WHITLEY (RHD)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:WHITLEY
Last Name:BERRY
Suffix:
Gender:F
Credentials:RHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0157
Mailing Address - Country:US
Mailing Address - Phone:573-663-2939
Mailing Address - Fax:
Practice Address - Street 1:115 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638
Practice Address - Country:US
Practice Address - Phone:573-663-2313
Practice Address - Fax:573-663-2322
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010018781124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist