Provider Demographics
NPI:1225450075
Name:GREGORY B KIVETT JR LLC
Entity Type:Organization
Organization Name:GREGORY B KIVETT JR LLC
Other - Org Name:ASSOCIATES OF DENTAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIVETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-781-5600
Mailing Address - Street 1:525 W 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2514
Mailing Address - Country:US
Mailing Address - Phone:417-781-5600
Mailing Address - Fax:417-623-5177
Practice Address - Street 1:525 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2514
Practice Address - Country:US
Practice Address - Phone:417-781-5600
Practice Address - Fax:417-623-5177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005015022261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental