=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790971976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOPLIN SURGICAL ARTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2007
-----------------------------------------------------
Last Update Date | 12/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 W 32ND ST STE B
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64804-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-781-4551
-----------------------------------------------------
Fax | 417-781-5809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 W 32ND ST STE B
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64804-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-781-4551
-----------------------------------------------------
Fax | 417-781-5809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DR. BRADLEY R BURNETT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 417-621-0500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 207-0
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------