Healthcare Provider Details

I. General information

NPI: 1093205130
Provider Name (Legal Business Name): OZARKS PREFERRED DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 E. SUNSHINE STE. Q
SPRINGFIELD MO
65804
US

IV. Provider business mailing address

3259 E. SUNSHINE STE. Q
SPRINGFIELD MO
65804
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-3220
  • Fax: 417-881-6473
Mailing address:
  • Phone: 417-881-3220
  • Fax: 417-881-6473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number015036
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT REYNOLDS
Title or Position: DENTST/OWNER
Credential: D.D.S.
Phone: 471-881-3220