Provider Demographics
NPI:1477755775
Name:BAGBY, MARK ROY (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROY
Last Name:BAGBY
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:PO BOX 2546
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-2546
Mailing Address - Country:US
Mailing Address - Phone:573-578-3499
Mailing Address - Fax:
Practice Address - Street 1:2935 BAGNELL DAM BLVD STE 112
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-8661
Practice Address - Country:US
Practice Address - Phone:578-349-9578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO152871223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO403024805Medicaid