Provider Demographics
NPI:1497172290
Name:COURTNEY L BEUSSINK DDS LLC
Entity Type:Organization
Organization Name:COURTNEY L BEUSSINK DDS LLC
Other - Org Name:FIRST STREET SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BEUSSINK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-238-3330
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:MARBLE HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63764-0650
Mailing Address - Country:US
Mailing Address - Phone:573-238-3330
Mailing Address - Fax:573-238-3464
Practice Address - Street 1:103 N FIRST ST
Practice Address - Street 2:
Practice Address - City:MARBLE HILL
Practice Address - State:MO
Practice Address - Zip Code:63764
Practice Address - Country:US
Practice Address - Phone:573-238-3330
Practice Address - Fax:573-238-3464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100161601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1023338860OtherNPI
1861580532OtherNPI