Provider Demographics
NPI:1093205130
Name:OZARKS PREFERRED DENTAL GROUP
Entity Type:Organization
Organization Name:OZARKS PREFERRED DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:471-881-3220
Mailing Address - Street 1:3259 E. SUNSHINE
Mailing Address - Street 2:STE. Q
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-881-3220
Mailing Address - Fax:417-881-6473
Practice Address - Street 1:3259 E. SUNSHINE
Practice Address - Street 2:STE. Q
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-881-3220
Practice Address - Fax:417-881-6473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015036122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty