Provider Demographics
NPI:1164033122
Name:DENTAL DEPOT OF BLUE SPRINGS PLLC
Entity Type:Organization
Organization Name:DENTAL DEPOT OF BLUE SPRINGS PLLC
Other - Org Name:DENTAL DEPOT OF BLUE SPRINGS PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROFESSIONAL RELATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GAYLON
Authorized Official - Middle Name:
Authorized Official - Last Name:ZISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-945-8941
Mailing Address - Street 1:2828 NW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7404
Mailing Address - Country:US
Mailing Address - Phone:816-295-7927
Mailing Address - Fax:816-874-6812
Practice Address - Street 1:1500 S 7 HWY
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-3943
Practice Address - Country:US
Practice Address - Phone:816-295-7927
Practice Address - Fax:816-874-6812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental