Provider Demographics
NPI:1205329737
Name:TAGUE, CAMILLE RENEE (DDS)
Entity type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:RENEE
Last Name:TAGUE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 S OAK AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4831
Mailing Address - Country:US
Mailing Address - Phone:913-709-6764
Mailing Address - Fax:
Practice Address - Street 1:2305 S BLACKMAN RD STE 100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-2845
Practice Address - Country:US
Practice Address - Phone:417-887-3860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-09
Last Update Date:2018-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018018453122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MONAOtherNA