MEDICARE: RICHARD M OMOHUNDRO D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12926	MO

General Provider Information

NPI Number	:	1811990880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD M OMOHUNDRO D.D.S.

Provider Business Mailing Address
First Line	:	1311 CEDARWOOD DR
Second Line	:
City	:	FULTON
State	:	MO
Zip	:	65251-2276
Country	:	US
Telephone Number	:	573-642-5075
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 E 2ND ST
Second Line	:
City	:	FULTON
State	:	MO
Zip	:	65251-1650
Country	:	US
Telephone Number	:	573-642-6624
Fax Number	:	573-642-6210

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/08/2007

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