Provider Demographics
NPI:1114035870
Name:TODD, TOMMY DEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TOMMY
Middle Name:DEAN
Last Name:TODD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 864
Mailing Address - Street 2:901 NORTH MAIN
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711
Mailing Address - Country:US
Mailing Address - Phone:417-926-3600
Mailing Address - Fax:417-926-7422
Practice Address - Street 1:901 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711
Practice Address - Country:US
Practice Address - Phone:417-926-3600
Practice Address - Fax:417-926-7422
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0141491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice