Provider Demographics
NPI:1568885762
Name:ROCKWELL DENTAL
Entity Type:Organization
Organization Name:ROCKWELL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:ROCKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-785-7071
Mailing Address - Street 1:1125 HERSCHEL BESS BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3071
Mailing Address - Country:US
Mailing Address - Phone:573-785-7071
Mailing Address - Fax:573-785-0523
Practice Address - Street 1:1125 HERSCHEL BESS BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3071
Practice Address - Country:US
Practice Address - Phone:573-785-7071
Practice Address - Fax:573-785-0523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130045841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty