Provider Demographics
NPI:1285984013
Name:OZARKS FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:OZARKS FAMILY DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-580-0521
Mailing Address - Street 1:1333W OUTER 21 ROAD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1333 W OUTER 21 RD
Practice Address - Street 2:
Practice Address - City:ARNOLD.
Practice Address - State:MO
Practice Address - Zip Code:63010
Practice Address - Country:US
Practice Address - Phone:870-580-0521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060127411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1891704193Medicaid
MO1215241005Medicaid