Provider Demographics
NPI:1235527490
Name:ASSOCIATED PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:ASSOCIATED PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BEYERSDORFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-622-0212
Mailing Address - Street 1:4945 STONE FALLS CTR
Mailing Address - Street 2:SUITE B
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7801
Mailing Address - Country:US
Mailing Address - Phone:618-622-0212
Mailing Address - Fax:
Practice Address - Street 1:4945 STONE FALLS CTR
Practice Address - Street 2:SUITE B
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7801
Practice Address - Country:US
Practice Address - Phone:618-622-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty