Healthcare Provider Details

I. General information

NPI: 1184483216
Provider Name (Legal Business Name): SPRINGFIELD CELEBRATE PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4214 S FARM ROAD 135
SPRINGFIELD MO
65810-3716
US

IV. Provider business mailing address

4214 S FARM ROAD 135
SPRINGFIELD MO
65810-3716
US

V. Phone/Fax

Practice location:
  • Phone: 417-289-0000
  • Fax:
Mailing address:
  • Phone: 417-289-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIKE MELANSON
Title or Position: OWNER
Credential: DMD
Phone: 417-289-0000