Provider Demographics
NPI:1790895043
Name:OPDAHL & BOWEN DDS PC
Entity Type:Organization
Organization Name:OPDAHL & BOWEN DDS PC
Other - Org Name:DRS ELIAS & OPDAHL DDS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:J
Authorized Official - Last Name:OPDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-478-3600
Mailing Address - Street 1:19201 E VALLEY VIEW PKWY
Mailing Address - Street 2:STE A
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6910
Mailing Address - Country:US
Mailing Address - Phone:816-478-3600
Mailing Address - Fax:816-478-0246
Practice Address - Street 1:19201 E VALLEY VIEW PKWY
Practice Address - Street 2:STE A
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6910
Practice Address - Country:US
Practice Address - Phone:816-478-3600
Practice Address - Fax:816-478-0246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013098122300000X
MO015713122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty