Provider Demographics
NPI:1023090081
Name:PREMIER DENTAL AND ORAL HEALTH GROUP
Entity type:Organization
Organization Name:PREMIER DENTAL AND ORAL HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:MASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FAGD
Authorized Official - Phone:573-365-0220
Mailing Address - Street 1:24 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-7111
Mailing Address - Country:US
Mailing Address - Phone:573-365-0220
Mailing Address - Fax:573-365-1962
Practice Address - Street 1:24 N SHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-7111
Practice Address - Country:US
Practice Address - Phone:573-365-0220
Practice Address - Fax:573-365-1962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0152261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty