NPIMap

Organization Active NPI

Edwardsville Family Dentist

  • Dental Clinic/Center
  • Edwardsville, IL
National Provider Identifier
1063899417
Registry record updated Jul 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental Clinic/CenterTaxonomy code 261QD0000X
License
019028093 Issued in IL
Legal business name
EDWARDSVILLE FAMILY DENTIST
Practice address
1811 Lindenwood Ave
Edwardsville, IL 62025-2580
Phone
(618) 659-0456
NPI assigned
May 5, 2015
Last updated
Jul 24, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 24, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Beau G Moody, DMDNPI 1780917823
Title
Dentist/Owner
Phone
(618) 659-0456

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X 019028093 IL Primary

Addresses

Primary practice location

1811 Lindenwood Ave
Edwardsville, IL 62025-2580

Mailing address

1811 Lindenwood Ave
Edwardsville, IL 62025-2580
Phone (618) 659-0456

National Provider Directory

National Provider Directory

Locations

122 N Kansas St
Edwardsville, IL 62025
Phone (618) 659-0456

1811 Lindenwood Ave
Edwardsville, IL 62025
Phone (618) 659-0456

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1430784000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690156800000",
    "number": "1063899417",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1811 LINDENWOOD AVE",
            "city": "EDWARDSVILLE",
            "state": "IL",
            "postal_code": "620252580",
            "telephone_number": "618-659-0456"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1811 LINDENWOOD AVE",
            "city": "EDWARDSVILLE",
            "state": "IL",
            "postal_code": "620252580",
            "telephone_number": "618-659-0456"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDWARDSVILLE FAMILY DENTIST",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-05-05",
        "last_updated": "2023-07-24",
        "certification_date": "2023-07-24",
        "status": "A",
        "authorized_official_last_name": "MOODY",
        "authorized_official_first_name": "BEAU",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "DENTIST/OWNER",
        "authorized_official_telephone_number": "618-659-0456",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "IL",
            "license": "019028093",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Edwardsville, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 24, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.