Provider Demographics
NPI:1285616235
Name:MASSIE, RONALD ERIC (DDS, FAGD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:ERIC
Last Name:MASSIE
Suffix:
Gender:M
Credentials:DDS, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-7111
Mailing Address - Country:US
Mailing Address - Phone:573-365-0220
Mailing Address - Fax:573-365-1962
Practice Address - Street 1:24 NORTH SHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65026-5721
Practice Address - Country:US
Practice Address - Phone:573-365-0220
Practice Address - Fax:573-365-1962
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0152261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000023508Medicare ID - Type Unspecified