Kevin Charles Beyersdorfer, DDS
Individual provider Active NPI Pediatric Dentistry · O Fallon, IL
NPI 1295814002 · NPPES record last updated Jun 11, 2008
Key facts
- NPI
- 1295814002
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatric Dentistry 1223P0221X
- License
- 019021773 (IL)
- Practice address
- 4945 Stone Falls Center
Ste B
O Fallon, IL 62269-7802 - Phone
- (618) 622-0212
- Fax
- (618) 622-1996
- NPI assigned
- Nov 3, 2006
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150609002779 | IL | Order and Referring Only - Other (Non-Physician) | 6406177906 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019021773 | IL | MD | Pediatric Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 019021773 | IL | Yes |
Addresses
Primary practice location
4945 Stone Falls Center
Ste B
O Fallon, IL 62269-7802
Mailing address
4945 Stone Falls Center
Suite B
O Fallon, IL 62269-7802
Phone (618) 622-0212
Other providers in O Fallon, IL
- Zachary Berg
- Ameniah V. Bernard
- Sally Berry
- Kaylah Kiwana Farrell Bess
- Jameilyn Bell Best-Hanson
- Shrinikethan Bharanidharan
- Harathi Bhooma
- Vinay Kumar Bhooma
- Casey Biancur
- Gregory Biddulph
All providers in O Fallon, IL · Pediatric Dentistry in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 11, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.