Provider Demographics
NPI:1639802309
Name:TRI-LAKES DENTAL CENTER
Entity Type:Organization
Organization Name:TRI-LAKES DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-337-0332
Mailing Address - Street 1:10994 HISTORIC HIGHWAY 165
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:MO
Mailing Address - Zip Code:65672-6234
Mailing Address - Country:US
Mailing Address - Phone:417-335-4630
Mailing Address - Fax:417-339-2026
Practice Address - Street 1:10994 HISTORIC HIGHWAY 165
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:MO
Practice Address - Zip Code:65672-6234
Practice Address - Country:US
Practice Address - Phone:417-335-4630
Practice Address - Fax:417-339-2026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental