Healthcare Provider Details

I. General information

NPI: 1811761190
Provider Name (Legal Business Name): DENTAL SAFARI CO MISSOURI, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7827 TOWN SQUARE AVE STE 104-1125
O FALLON MO
63368-7197
US

IV. Provider business mailing address

7562 OLD ROUTE 13
MARION IL
62959-7776
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-8333
  • Fax:
Mailing address:
  • Phone: 618-993-8333
  • Fax: 618-993-8335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK ANDREW MORLEY
Title or Position: MANAGER
Credential: JD
Phone: 618-559-6662