Beau Devereux Butzirus, DMD
Individual provider Active NPI Dentist · Cottleville, MO
NPI 1629637764 · NPPES record last updated Mar 18, 2024
Key facts
- NPI
- 1629637764
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 2019020087 (MO)
- Practice address
- 475 Miralago Shore Dr
Cottleville, MO 63376-3189 - Phone
- (636) 928-4090
- Fax
- (636) 928-4555
- NPI assigned
- Jun 12, 2019
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 6
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MO
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20190718003655 | MO | Order and Referring Only - Dentist |
4385970979 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2019020087 | MO | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Tanner Brown DMD LLC | Current |
Accepting new patients | |
| DRS.Kraner and Kraner , LLC | Past |
Accepting new patients | |
| Bryan Watanabe DDS, White Oaks Dental Group, PC | Dentist | Past |
Accepting new patients |
| Tanner Brown DMD LLC | Past |
Accepting new patients | |
| Alex Sharifian DDS Blue Springs Dentistry PC | Past | Accepting new patients | |
| Kraner Family Dentistry | Past |
Accepting new patients |
Locations
475 Miralago Shore Dr
Saint Peters, MO 63376
Phone (636) 928-4090
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 2019020087 | MO | Yes |
Addresses
Primary practice location
475 Miralago Shore Dr
Cottleville, MO 63376-3189
Mailing address
475 Miralago Shore Dr
Cottleville, MO 63376-3189
Phone (369) 284-0906
Other providers in Cottleville, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 18, 2024. 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.