Provider Demographics
NPI:1518427079
Name:MISSOURI DENTAL SPECIALISTS
Entity Type:Organization
Organization Name:MISSOURI DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:LIVINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-298-4400
Mailing Address - Street 1:1002 DIAMOND RDG STE 1500
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-7914
Mailing Address - Country:US
Mailing Address - Phone:573-298-4400
Mailing Address - Fax:573-616-1489
Practice Address - Street 1:1002 DIAMOND RDG STE 1500
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-7914
Practice Address - Country:US
Practice Address - Phone:573-298-4400
Practice Address - Fax:573-616-1489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty