Provider Demographics
NPI:1063760460
Name:PLAZA DENTAL IMPLANT & SURGICAL CENTER, LLC
Entity type:Organization
Organization Name:PLAZA DENTAL IMPLANT & SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:PFITZINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-817-2220
Mailing Address - Street 1:303 N KEENE ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7193
Mailing Address - Country:US
Mailing Address - Phone:573-817-2220
Mailing Address - Fax:573-817-2808
Practice Address - Street 1:303 N KEENE ST
Practice Address - Street 2:SUITE 209
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7193
Practice Address - Country:US
Practice Address - Phone:573-817-2220
Practice Address - Fax:573-817-2808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO010435122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty