=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063760460
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLAZA DENTAL IMPLANT & SURGICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2012
-----------------------------------------------------
Last Update Date | 08/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 N KEENE ST SUITE 209
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65201-7193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-817-2220
-----------------------------------------------------
Fax | 573-817-2808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 N KEENE ST SUITE 209
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65201-7193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-817-2220
-----------------------------------------------------
Fax | 573-817-2808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WALTER PFITZINGER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 573-817-2220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 010435
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------