Provider Demographics
NPI:1851503163
Name:BROYLES, IRENE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:
Last Name:BROYLES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-9729
Mailing Address - Country:US
Mailing Address - Phone:816-331-3456
Mailing Address - Fax:816-331-0035
Practice Address - Street 1:209 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083-9729
Practice Address - Country:US
Practice Address - Phone:816-331-3456
Practice Address - Fax:816-331-0035
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0154601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO421427364OtherTAX ID