Healthcare Provider Details

I. General information

NPI: 1427857127
Provider Name (Legal Business Name): RIVER WILLOW DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WAINWRIGHT ST STE 210
WASHINGTON MO
63090
US

IV. Provider business mailing address

2 WAINWRIGHT ST STE 210
WASHINGTON MO
63090
US

V. Phone/Fax

Practice location:
  • Phone: 636-392-6797
  • Fax: 636-392-6792
Mailing address:
  • Phone: 636-392-6797
  • Fax: 636-392-6792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARTIN BRUNWORTH
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 636-392-6797