Provider Demographics
NPI:1972040699
Name:RM DENTAL GROUP EAST
Entity Type:Organization
Organization Name:RM DENTAL GROUP EAST
Other - Org Name:GRAIN VALLEY FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-230-6862
Mailing Address - Street 1:655 R D MIZE RD.
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029
Mailing Address - Country:US
Mailing Address - Phone:816-229-4560
Mailing Address - Fax:
Practice Address - Street 1:4516 BROADWAY
Practice Address - Street 2:UNIT 301
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3381
Practice Address - Country:US
Practice Address - Phone:573-230-6862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010016286122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty