Provider Demographics
NPI:1508330986
Name:EXCELSIOR SPRINGS FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:EXCELSIOR SPRINGS FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-630-5713
Mailing Address - Street 1:196 S. MCCLEARY RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024
Mailing Address - Country:US
Mailing Address - Phone:816-630-5713
Mailing Address - Fax:816-630-0392
Practice Address - Street 1:196 S. MCCLEARY RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024
Practice Address - Country:US
Practice Address - Phone:816-630-5713
Practice Address - Fax:816-630-0392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-18
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063426799OtherDDS
MO1306850680OtherDDS