Healthcare Provider Details

I. General information

NPI: 1639618325
Provider Name (Legal Business Name): TABITHA VOLLMER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W. SUNSHINE STREET SUITE Q
SPRINGFIELD MO
65807-2261
US

IV. Provider business mailing address

1701 W SUNSHINE SUITE Q
SPRINGFIELD MO
65807-2261
US

V. Phone/Fax

Practice location:
  • Phone: 417-501-1048
  • Fax: 417-501-1661
Mailing address:
  • Phone: 417-501-1048
  • Fax: 417-501-1661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number2016004424
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2012022466
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number2016004425
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number2016004427
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number2016004422
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: