Provider Demographics
NPI:1912933235
Name:KAVANAUGH, CHARLES EDWARD (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWARD
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9401 N OAK TRFY
Mailing Address - Street 2:SUITE #120
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-2233
Mailing Address - Country:US
Mailing Address - Phone:816-452-2206
Mailing Address - Fax:816-452-2247
Practice Address - Street 1:9401 N OAK TRFY
Practice Address - Street 2:SUITE #120
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2233
Practice Address - Country:US
Practice Address - Phone:816-452-2206
Practice Address - Fax:816-452-2247
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO104571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10457OtherMISSOURI LICENSE NUMBER