Provider Demographics
NPI:1902953391
Name:WESTPORT PERIODONTICS P.C.
Entity Type:Organization
Organization Name:WESTPORT PERIODONTICS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:H
Authorized Official - Last Name:KYD
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-434-4676
Mailing Address - Street 1:77 WESTPORT PLZ
Mailing Address - Street 2:SUITE 367
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3107
Mailing Address - Country:US
Mailing Address - Phone:314-434-4676
Mailing Address - Fax:314-434-6806
Practice Address - Street 1:77 WESTPORT PLZ
Practice Address - Street 2:SUITE 367
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3107
Practice Address - Country:US
Practice Address - Phone:314-434-4676
Practice Address - Fax:314-434-6806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty