Healthcare Provider Details

I. General information

NPI: 1639313752
Provider Name (Legal Business Name): RICKY D. POWELL, D.D.S., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 BOONE VILLA DR B
BOONVILLE MO
65233-2050
US

IV. Provider business mailing address

1945 BOONE VILLA DR B
BOONVILLE MO
65233-2050
US

V. Phone/Fax

Practice location:
  • Phone: 660-882-6452
  • Fax:
Mailing address:
  • Phone: 660-882-6452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13147
License Number StateMO

VIII. Authorized Official

Name: DR. RICKY DARYL POWELL
Title or Position: OWNER
Credential: D.D.S.
Phone: 660-882-6452