Provider Demographics
NPI:1013229749
Name:SOUTHEAST MISSOURI HEALTH NETWORK
Entity Type:Organization
Organization Name:SOUTHEAST MISSOURI HEALTH NETWORK
Other - Org Name:OTTO BEAN DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-748-2404
Mailing Address - Street 1:420 SEMO DR
Mailing Address - Street 2:P.O. BOX 400
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-1734
Mailing Address - Country:US
Mailing Address - Phone:573-748-2404
Mailing Address - Fax:573-748-8929
Practice Address - Street 1:500 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2102
Practice Address - Country:US
Practice Address - Phone:573-888-3000
Practice Address - Fax:573-888-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-10
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1013229749Medicaid