Provider Demographics
NPI:1972014504
Name:ROCK DENTAL MISSOURI LLC
Entity Type:Organization
Organization Name:ROCK DENTAL MISSOURI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANEQUE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PHILMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-781-2777
Mailing Address - Street 1:PO BOX 3450
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-3450
Mailing Address - Country:US
Mailing Address - Phone:501-781-2777
Mailing Address - Fax:
Practice Address - Street 1:181 N KENTUCKY AVE STE 300
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2092
Practice Address - Country:US
Practice Address - Phone:417-256-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty