Provider Demographics
NPI:1619469848
Name:BUSWELL, MATTHEW LEE (DDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:BUSWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 BROOKLYN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64124-2985
Mailing Address - Country:US
Mailing Address - Phone:816-315-7432
Mailing Address - Fax:
Practice Address - Street 1:3407 BERRYWOOD DR STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6500
Practice Address - Country:US
Practice Address - Phone:573-603-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180175871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018017587OtherMISSOURI STATE LICENSE