Provider Demographics
NPI:1457495681
Name:POWELL, RICKY D (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:D
Last Name:POWELL
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 1:1945B BOONE VILLA DR
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-1987
Mailing Address - Country:US
Mailing Address - Phone:660-882-6452
Mailing Address - Fax:
Practice Address - Street 1:1945B BOONE VILLA DR
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-1987
Practice Address - Country:US
Practice Address - Phone:660-882-6452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO131471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice