Provider Demographics
NPI:1750166484
Name:OP ORTHODONTICS OF MISSOURI
Entity type:Organization
Organization Name:OP ORTHODONTICS OF MISSOURI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-283-8867
Mailing Address - Street 1:5300 PATTERSON AVE SE STE 110
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9758
Mailing Address - Country:US
Mailing Address - Phone:616-283-8867
Mailing Address - Fax:
Practice Address - Street 1:12111 TESSON FERRY PROFESSIONAL CTR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-1250
Practice Address - Country:US
Practice Address - Phone:314-635-7510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OP ORTHODONTICS OF MISSOURI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-30
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty