Healthcare Provider Details

I. General information

NPI: 1396196234
Provider Name (Legal Business Name): PRYOR FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W ELSIE ST
VAN BUREN MO
63965
US

IV. Provider business mailing address

PO BOX 339
VAN BUREN MO
63965-0339
US

V. Phone/Fax

Practice location:
  • Phone: 573-323-4287
  • Fax: 573-323-8120
Mailing address:
  • Phone: 573-323-4287
  • Fax: 573-323-8120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DARREN PRYOR
Title or Position: BUSINESS MGR
Credential:
Phone: 573-323-4287