Provider Demographics
NPI:1669711321
Name:IRENE AVES BROYLES DDS PC
Entity type:Organization
Organization Name:IRENE AVES BROYLES DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:AVES
Authorized Official - Last Name:BROYLES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-331-3456
Mailing Address - Street 1:PO BOX 1125
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-1125
Mailing Address - Country:US
Mailing Address - Phone:816-331-3456
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty