Provider Demographics
NPI:1699745935
Name:HANNIBAL DENTAL GROUP
Entity type:Organization
Organization Name:HANNIBAL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:LUEBRECHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-221-1227
Mailing Address - Street 1:2727 SAINT MARYS AVE
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-3774
Mailing Address - Country:US
Mailing Address - Phone:573-221-1227
Mailing Address - Fax:573-221-5564
Practice Address - Street 1:2727 SAINT MARYS AVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-3774
Practice Address - Country:US
Practice Address - Phone:573-221-1227
Practice Address - Fax:573-221-5564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO98811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501174OtherINSURANCE
MO501065OtherINSURANCE
MO818028OtherINSURANCE
MO501160OtherINSURANCE
MO74007199OtherINSURANCE
MO409534OtherINSURANCE
MO409535OtherINSURANCE
MO74014433OtherINSURANCE
MO74014632OtherINSURANCE
MO74017142OtherINSURANCE
MOM00100OtherINSURANCE
MOM00100OtherINSURANCE