Provider Demographics
NPI:1972791986
Name:MISSOURI DENTAL PROFESSIONALS, RICHARD STRAUS, DMD, PC
Entity Type:Organization
Organization Name:MISSOURI DENTAL PROFESSIONALS, RICHARD STRAUS, DMD, PC
Other - Org Name:BREVCO FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8513
Mailing Address - Street 1:100 BREVCO PLAZA
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367
Mailing Address - Country:US
Mailing Address - Phone:636-561-9000
Mailing Address - Fax:636-561-9001
Practice Address - Street 1:100 BREVCO PLAZA
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367
Practice Address - Country:US
Practice Address - Phone:636-561-9000
Practice Address - Fax:636-561-9001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSOURI DENTAL PROFESSIONALS, RICHARD STRAUS, DMD, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-04
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO139501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty