MEDICARE: OZARK PREFERRED DENTAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)
2	122300000X	Dentist	015036	MO

General Provider Information

NPI Number	:	1467750745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OZARK PREFERRED DENTAL GROUP

Provider Business Mailing Address
First Line	:	3211 E BATTLEFIELD ST
Second Line	:	SUITE 100
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4050
Country	:	US
Telephone Number	:	417-881-3220
Fax Number	:	417-881-6473

Provider Business Practice Location Address
First Line	:	3211 E BATTLEFIELD ST
Second Line	:	SUITE 100
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4050
Country	:	US
Telephone Number	:	417-881-3220
Fax Number	:	417-881-6473

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROBERT KEITH REYNOLDS
Credential	:	DDS
Telephone Number	:	417-881-3220

Provider Enumeration Date	:	03/10/2011
Last Update Date	:	03/23/2011

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