Basic Information
| Provider Information | |||||||||
| NPI: | 1821739087 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYD | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | LASETER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 W BRIARBROOK LN | ||||||||
| Address2: | |||||||||
| City: | CARL JUNCTION | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648349245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175404332 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 530 S MAIDEN LN | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648013084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177820080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2022 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2022018774 | MO | Y | Dental Providers | Dentist |
No ID Information.