Provider Demographics
NPI:1912109646
Name:MISSOURI DENTAL PROFESSIONALS, RICHARD STRAUS, DMD, PC
Entity Type:Organization
Organization Name:MISSOURI DENTAL PROFESSIONALS, RICHARD STRAUS, DMD, PC
Other - Org Name:CREATIVE SMILES AT WINGHAVEN
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 1:3011 WINGHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3600
Mailing Address - Country:US
Mailing Address - Phone:636-561-6035
Mailing Address - Fax:636-561-6066
Practice Address - Street 1:3011 WINGHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3600
Practice Address - Country:US
Practice Address - Phone:636-561-6035
Practice Address - Fax:636-561-6066
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSOURI DENTAL PROFESSIONALS, RICHARD STRAUS, DMD, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-04
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty