Provider Demographics
NPI:1477824662
Name:MBD MERGER LLC
Entity Type:Organization
Organization Name:MBD MERGER LLC
Other - Org Name:CROWE & MCGUIRE ORTHODONTICS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ORTHODONTIST/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:573-334-5755
Mailing Address - Street 1:1736 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701
Mailing Address - Country:US
Mailing Address - Phone:573-334-5755
Mailing Address - Fax:573-334-1501
Practice Address - Street 1:1736 BROADWAY
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701
Practice Address - Country:US
Practice Address - Phone:573-334-5755
Practice Address - Fax:573-334-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006015824122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty