Provider Demographics
NPI:1275593618
Name:BACON, PAMELA M (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:M
Last Name:BACON
Suffix:
Gender:F
Credentials:DMD
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 1084
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65615-1084
Mailing Address - Country:US
Mailing Address - Phone:417-231-1500
Mailing Address - Fax:
Practice Address - Street 1:515 BEE CREEK RD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7734
Practice Address - Country:US
Practice Address - Phone:417-336-8478
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015055122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist