Provider Demographics
NPI:1912276809
Name:BUFFALO PRAIRIE DENTAL
Entity Type:Organization
Organization Name:BUFFALO PRAIRIE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:THROCKMORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-345-2793
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:1006 S. ASH
Mailing Address - City:BUFFALO
Mailing Address - State:MO
Mailing Address - Zip Code:65622-0707
Mailing Address - Country:US
Mailing Address - Phone:417-345-2793
Mailing Address - Fax:417-345-8654
Practice Address - Street 1:1006 S. ASH
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MO
Practice Address - Zip Code:65622-0707
Practice Address - Country:US
Practice Address - Phone:417-345-2793
Practice Address - Fax:417-345-8654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO012536122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty