Provider Demographics
NPI:1659738631
Name:DYNAMIC DNA LABORATORIES, LLC
Entity Type:Organization
Organization Name:DYNAMIC DNA LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, GENERAL SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:DAVID LEE
Authorized Official - Last Name:O'REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:417-861-6723
Mailing Address - Street 1:2144 E REPUBLIC RD
Mailing Address - Street 2:SUITE B204
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4623
Mailing Address - Country:US
Mailing Address - Phone:417-319-1047
Mailing Address - Fax:
Practice Address - Street 1:2144 E REPUBLIC RD
Practice Address - Street 2:SUITE B204
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4623
Practice Address - Country:US
Practice Address - Phone:417-319-1047
Practice Address - Fax:417-319-7142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001418393291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory