Healthcare Provider Details

I. General information

NPI: 1073393336
Provider Name (Legal Business Name): TAILWATER PRACTICE PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E 10TH ST
ROLLA MO
65401-4601
US

IV. Provider business mailing address

10 BURTON HILLS BLVD STE 400
NASHVILLE TN
37215-3004
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-1599
  • Fax:
Mailing address:
  • Phone: 615-479-2196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN MCCOSTLIN
Title or Position: CEO
Credential:
Phone: 615-479-2196