Healthcare Provider Details

I. General information

NPI: 1417881244
Provider Name (Legal Business Name): CLEAR CREEK FAMILY DENTAL - MT. VERNON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 S LANDRUM ST
MOUNT VERNON MO
65712-1931
US

IV. Provider business mailing address

1103 S LANDRUM ST
MOUNT VERNON MO
65712-1931
US

V. Phone/Fax

Practice location:
  • Phone: 417-427-9123
  • Fax: 417-268-9121
Mailing address:
  • Phone: 417-427-9123
  • Fax: 417-268-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA TANNER RUST
Title or Position: OWNER
Credential: DDS
Phone: 417-427-9123