Provider Demographics
NPI:1295814002
Name:BEYERSDORFER, KEVIN CHARLES (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHARLES
Last Name:BEYERSDORFER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4945 STONE FALLS CENTER
Mailing Address - Street 2:SUITE B
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7802
Mailing Address - Country:US
Mailing Address - Phone:618-622-0212
Mailing Address - Fax:618-622-1996
Practice Address - Street 1:4945 STONE FALLS CENTER
Practice Address - Street 2:STE B
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7802
Practice Address - Country:US
Practice Address - Phone:618-622-0212
Practice Address - Fax:618-622-1996
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190217731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry