Provider Demographics
NPI:1144469370
Name:NEVADA FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:NEVADA FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-667-3006
Mailing Address - Street 1:402 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2458
Mailing Address - Country:US
Mailing Address - Phone:417-667-3006
Mailing Address - Fax:417-667-4579
Practice Address - Street 1:402 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-2458
Practice Address - Country:US
Practice Address - Phone:417-667-3006
Practice Address - Fax:417-667-4579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0119601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty