Provider Demographics
NPI:1346598661
Name:BYRON DUVALL DDS LLC
Entity Type:Organization
Organization Name:BYRON DUVALL DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:V
Authorized Official - Last Name:DUVALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-776-7100
Mailing Address - Street 1:2600 CHOUTEAU AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-3013
Mailing Address - Country:US
Mailing Address - Phone:314-776-7100
Mailing Address - Fax:
Practice Address - Street 1:2600 CHOUTEAU AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-3013
Practice Address - Country:US
Practice Address - Phone:314-776-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO401339304Medicaid