Provider Demographics
NPI:1548445406
Name:PLAZA DENTAL GROUP LLC
Entity type:Organization
Organization Name:PLAZA DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOOTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-817-2222
Mailing Address - Street 1:303 N KEENE ST
Mailing Address - Street 2:STE 208
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6623
Mailing Address - Country:US
Mailing Address - Phone:573-817-2222
Mailing Address - Fax:573-817-2888
Practice Address - Street 1:303 N KEENE ST
Practice Address - Street 2:STE 208
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6623
Practice Address - Country:US
Practice Address - Phone:573-817-2222
Practice Address - Fax:573-817-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006135081223G0001X
MO013481223P0221X
MO0104351223P0221X
MO20080066451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty