Provider Demographics
NPI:1326425711
Name:BRACES OF THE OZARKS, LLC
Entity Type:Organization
Organization Name:BRACES OF THE OZARKS, LLC
Other - Org Name:BRANSON BRACES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-781-2777
Mailing Address - Street 1:PO BOX 24470
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72221-4470
Mailing Address - Country:US
Mailing Address - Phone:501-781-2777
Mailing Address - Fax:
Practice Address - Street 1:168 S PAYNE STEWART DR
Practice Address - Street 2:STE 100
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2792
Practice Address - Country:US
Practice Address - Phone:417-414-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1043609522Medicaid