Provider Demographics
NPI:1003283904
Name:PROGRESSIVE ORTHODONTICS LLC
Entity Type:Organization
Organization Name:PROGRESSIVE ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SENTHIL
Authorized Official - Middle Name:N
Authorized Official - Last Name:ARUN
Authorized Official - Suffix:
Authorized Official - Credentials:BDS, DMD, MSD, PH D
Authorized Official - Phone:706-288-7538
Mailing Address - Street 1:3306 EMERALD LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6880
Mailing Address - Country:US
Mailing Address - Phone:573-206-8777
Mailing Address - Fax:
Practice Address - Street 1:3306 EMERALD LN
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6880
Practice Address - Country:US
Practice Address - Phone:573-206-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130094391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty