Provider Demographics
NPI:1558669556
Name:MISSOURI DENTAL PROFESSIONALS, RICHARD STRAUS, DMD, PC
Entity Type:Organization
Organization Name:MISSOURI DENTAL PROFESSIONALS, RICHARD STRAUS, DMD, PC
Other - Org Name:FAIRVIEW DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8513
Mailing Address - Street 1:2901 W BROADWAY STE 109
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-0669
Mailing Address - Country:US
Mailing Address - Phone:573-445-5811
Mailing Address - Fax:573-445-5819
Practice Address - Street 1:2901 W BROADWAY STE 109
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-0669
Practice Address - Country:US
Practice Address - Phone:573-445-5811
Practice Address - Fax:573-445-5819
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSOURI DENTAL PROFESSIONALS, RICHARD STRAUS, DMD, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-01
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty