Provider Demographics
NPI:1184008955
Name:BRENDA HERRMAN, DDS, LLC
Entity Type:Organization
Organization Name:BRENDA HERRMAN, DDS, LLC
Other - Org Name:SPRING LAKE DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-838-9199
Mailing Address - Street 1:PO BOX 455
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355-0455
Mailing Address - Country:US
Mailing Address - Phone:660-438-7355
Mailing Address - Fax:660-438-7356
Practice Address - Street 1:601 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:MO
Practice Address - Zip Code:65355-3412
Practice Address - Country:US
Practice Address - Phone:660-438-7355
Practice Address - Fax:660-438-7356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-12
Last Update Date:2015-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE015183122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty