Healthcare Provider Details

I. General information

NPI: 1285093328
Provider Name (Legal Business Name): SPOT 2, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 E MONTCLAIR ST
SPRINGFIELD MO
65804-4245
US

IV. Provider business mailing address

1712 PIONEER AVE STE 5651A
CHEYENNE WY
82001-4406
US

V. Phone/Fax

Practice location:
  • Phone: 417-886-9939
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2008019818
License Number StateMO

VIII. Authorized Official

Name: SHAYNA BAHR
Title or Position: MEMBER
Credential: DMD
Phone: 303-524-4501