=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336714732
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BATTLEFIELD MODERN DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2021
-----------------------------------------------------
Last Update Date | 06/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5469 S STATE HIGHWAY FF
-----------------------------------------------------
City | BATTLEFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65619-9825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-447-5180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5469 S STATE HIGHWAY FF
-----------------------------------------------------
City | BATTLEFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65619-9825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-447-5180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NATHAN BOWEN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 702-283-8421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------