Healthcare Provider Details

I. General information

NPI: 1992432447
Provider Name (Legal Business Name): GRAND DENTAL STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

948 S JEFFERSON AVE
SPRINGFIELD MO
65806-3204
US

IV. Provider business mailing address

948 S JEFFERSON AVE
SPRINGFIELD MO
65806-3204
US

V. Phone/Fax

Practice location:
  • Phone: 417-861-8876
  • Fax:
Mailing address:
  • Phone: 417-865-8405
  • 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: NICHOLAS R MATTHEWS
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 417-865-8405