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General NPI Number Information
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NPI Number | 1992432447
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Entity Type | Organization
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Legal Business Name | GRAND DENTAL STUDIO LLC
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Dates
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Enumeration Date | 08/04/2022
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Last Update Date | 03/29/2023
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Provider Practice Location Address
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Address Line | 948 S JEFFERSON AVE
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City | SPRINGFIELD
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State | MO
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Zip | 65806-3204
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Country | US
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Telephone | 417-861-8876
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Fax |
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Provider Business Mailing Address
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Address Line | 948 S JEFFERSON AVE
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City | SPRINGFIELD
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State | MO
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Zip | 65806-3204
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Country | US
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Telephone | 417-865-8405
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | NICHOLAS R MATTHEWS
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Credential | DDS
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Telephone | 417-865-8405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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