Healthcare Provider Details

I. General information

NPI: 1518427079
Provider Name (Legal Business Name): MISSOURI DENTAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 DIAMOND RDG STE 1500
JEFFERSON CITY MO
65109-7914
US

IV. Provider business mailing address

1002 DIAMOND RDG STE 1500
JEFFERSON CITY MO
65109-7914
US

V. Phone/Fax

Practice location:
  • Phone: 573-298-4400
  • Fax: 573-616-1489
Mailing address:
  • Phone: 573-298-4400
  • Fax: 573-616-1489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: EDNA ROSE LIVINGSTON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 573-298-4400