Provider Demographics
NPI:1194191213
Name:MIDWESTPERIODONTICS
Entity Type:Organization
Organization Name:MIDWESTPERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-390-2500
Mailing Address - Street 1:1006 W SAINT MAARTENS DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2966
Mailing Address - Country:US
Mailing Address - Phone:816-364-3325
Mailing Address - Fax:
Practice Address - Street 1:1006 W SAINT MAARTENS DR
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2966
Practice Address - Country:US
Practice Address - Phone:816-364-3325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO144011223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty