Provider Demographics
NPI:1528635919
Name:BLUE CEDAR DENTISTRY LLC
Entity type:Organization
Organization Name:BLUE CEDAR DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-283-8421
Mailing Address - Street 1:121 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1517
Practice Address - Country:US
Practice Address - Phone:702-283-8421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-05
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental