Provider Demographics
NPI:1538622071
Name:SMILE SAFARI OF MISSOURI
Entity type:Organization
Organization Name:SMILE SAFARI OF MISSOURI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIZENDINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-563-8681
Mailing Address - Street 1:1709 S MUR LEN RD
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-2611
Mailing Address - Country:US
Mailing Address - Phone:913-353-4001
Mailing Address - Fax:
Practice Address - Street 1:10016 E 63RD ST
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-5102
Practice Address - Country:US
Practice Address - Phone:816-313-8485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental