Provider Demographics
NPI:1336548106
Name:PEDS, LLC
Entity type:Organization
Organization Name:PEDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-972-7751
Mailing Address - Street 1:4741 CENTRAL ST
Mailing Address - Street 2:SUITE #107
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64112-1533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4741 CENTRAL ST
Practice Address - Street 2:SUITE #107
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64112-1533
Practice Address - Country:US
Practice Address - Phone:402-972-7751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140127371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty