Provider Demographics
NPI:1982827465
Name:WEST EDGEWOOD DENTAL SMALL SMILES, LLC
Entity Type:Organization
Organization Name:WEST EDGEWOOD DENTAL SMALL SMILES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-638-3897
Mailing Address - Street 1:3306 EMERALD LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6877
Mailing Address - Country:US
Mailing Address - Phone:573-638-3897
Mailing Address - Fax:573-761-0515
Practice Address - Street 1:3306 EMERALD LN
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6877
Practice Address - Country:US
Practice Address - Phone:573-638-3897
Practice Address - Fax:573-761-0515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty