Healthcare Provider Details

I. General information

NPI: 1972014504
Provider Name (Legal Business Name): ROCK DENTAL MISSOURI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 N KENTUCKY AVE STE 300
WEST PLAINS MO
65775-2092
US

IV. Provider business mailing address

PO BOX 3450
LITTLE ROCK AR
72203-3450
US

V. Phone/Fax

Practice location:
  • Phone: 417-256-5100
  • Fax:
Mailing address:
  • Phone: 501-781-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: SHANEQUE S PHILMON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 501-462-2062