Provider Demographics
NPI:1598016008
Name:DYNASTY DENTAL LLC
Entity Type:Organization
Organization Name:DYNASTY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-494-7967
Mailing Address - Street 1:810 OFALLON RD
Mailing Address - Street 2:ST E 70
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-8102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 OFALLON RD
Practice Address - Street 2:STE 70
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-8102
Practice Address - Country:US
Practice Address - Phone:636-699-9815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO152281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty