Basic Information
| Provider Information | |||||||||
| NPI: | 1568904381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CELEBRACES GLADSTONE FERGUSON DDS LLC | ||||||||
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| OtherOrganizationName: | CELEBRATE DENTAL & BRACES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 NE VIVION RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641184510 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 319 NE VIVION RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641184510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104510000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2016 | ||||||||
| LastUpdateDate: | 01/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | FERGUSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2104510000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS, CAGS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 2008028696 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.