Healthcare Provider Details

I. General information

NPI: 1023090081
Provider Name (Legal Business Name): PREMIER DENTAL AND ORAL HEALTH GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 N SHORE DR
LAKE OZARK MO
65049-7111
US

IV. Provider business mailing address

24 N SHORE DR
LAKE OZARK MO
65049-7111
US

V. Phone/Fax

Practice location:
  • Phone: 573-365-0220
  • Fax: 573-365-1962
Mailing address:
  • Phone: 573-365-0220
  • Fax: 573-365-1962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number015226
License Number StateMO

VIII. Authorized Official

Name: RONALD ERIC MASSIE
Title or Position: PRESIDENT
Credential: DDS, FAGD
Phone: 573-365-0220