| Organization Name: | EDWARDSVILLE FAMILY DENTIST |
| NPI Number: | 1063899417 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BEAU G MOODY (DENTIST/OWNER) |
| Mailing Address: | 122 N Kansas St Edwardsville |
| State: | IL US |
| Postal Code: | 620251769 |
| Phone Number: | 6186590456 |
| Fax Number: | |
| NPI Enumeration Date: | 05/05/2015 |
| NPI Last Update Date: | 05/05/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 019028093 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |