1184094880 NPI number — PREMIER DENTAL & ORAL HEALTH GROUP,P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184094880 NPI number — PREMIER DENTAL & ORAL HEALTH GROUP,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER DENTAL & ORAL HEALTH GROUP,P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184094880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 N SHORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE OZARK
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65049-7111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-365-0220
Provider Business Mailing Address Fax Number:
573-365-1962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 N SHORE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE OZARK
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65049-7111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-365-0220
Provider Business Practice Location Address Fax Number:
573-365-1962
Provider Enumeration Date:
10/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MASSIE
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT/ OWNER
Authorized Official Telephone Number:
573-365-0220

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  15226 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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