Provider Demographics
NPI:1063447860
Name:REZNICEK DENTAL GROUP LLC
Entity Type:Organization
Organization Name:REZNICEK DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:REZNICEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-774-6101
Mailing Address - Street 1:1400 STATE ROUTE F
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2831
Mailing Address - Country:US
Mailing Address - Phone:573-774-6101
Mailing Address - Fax:573-774-6812
Practice Address - Street 1:1400 STATE ROUTE F
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2831
Practice Address - Country:US
Practice Address - Phone:573-774-6101
Practice Address - Fax:573-774-6812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0148651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty