Provider Demographics
NPI:1730365529
Name:GLADSTONE FAMILY DENTISTRY L.L.C.
Entity type:Organization
Organization Name:GLADSTONE FAMILY DENTISTRY L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HEISKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-452-2420
Mailing Address - Street 1:6301 N OAK TRFY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-4705
Mailing Address - Country:US
Mailing Address - Phone:816-452-2420
Mailing Address - Fax:816-777-0836
Practice Address - Street 1:6301 N OAK TRFY
Practice Address - Street 2:SUITE 202
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-4705
Practice Address - Country:US
Practice Address - Phone:816-452-2420
Practice Address - Fax:816-777-0836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO011945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE09692040OtherBLUE CROSS