Healthcare Provider Details

I. General information

NPI: 1164033122
Provider Name (Legal Business Name): DENTAL DEPOT OF BLUE SPRINGS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S 7 HWY
BLUE SPRINGS MO
64014-3943
US

IV. Provider business mailing address

2828 NW 30TH ST
OKLAHOMA CITY OK
73112-7404
US

V. Phone/Fax

Practice location:
  • Phone: 816-295-7927
  • Fax: 816-874-6812
Mailing address:
  • Phone: 816-295-7927
  • Fax: 816-874-6812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GAYLON ZISSA
Title or Position: PROFESSIONAL RELATIONS MANAGER
Credential:
Phone: 405-945-8941