Provider Demographics
NPI:1730401738
Name:EASTLAND FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:EASTLAND FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-795-7007
Mailing Address - Street 1:19401 E 40 HWY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-5450
Mailing Address - Country:US
Mailing Address - Phone:816-795-7007
Mailing Address - Fax:816-795-7073
Practice Address - Street 1:19401 E 40 HWY
Practice Address - Street 2:SUITE 180
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-5450
Practice Address - Country:US
Practice Address - Phone:816-795-7007
Practice Address - Fax:816-795-7073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030118491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty