Provider Demographics
NPI:1720398910
Name:RICHARD MCDERMOTT DDS MS ORTHODONTICS LLC
Entity Type:Organization
Organization Name:RICHARD MCDERMOTT DDS MS ORTHODONTICS LLC
Other - Org Name:LEGACY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-281-3399
Mailing Address - Street 1:3837 VAILE AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034
Mailing Address - Country:US
Mailing Address - Phone:314-831-9399
Mailing Address - Fax:314-831-8146
Practice Address - Street 1:3837 VAILE AVE
Practice Address - Street 2:SUTIE G
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034
Practice Address - Country:US
Practice Address - Phone:314-831-9399
Practice Address - Fax:314-831-8146
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD MCDERMOTT DDS MS ORTHODONTICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO31267261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental