Provider Demographics
NPI:1679070841
Name:ACCESS DENTAL & DENTURES LLC
Entity type:Organization
Organization Name:ACCESS DENTAL & DENTURES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-501-1082
Mailing Address - Street 1:1701 W SUNSHINE ST STE Q
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-2261
Mailing Address - Country:US
Mailing Address - Phone:417-501-1048
Mailing Address - Fax:417-501-1661
Practice Address - Street 1:1402 S ELLIOTT AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2104
Practice Address - Country:US
Practice Address - Phone:417-501-1082
Practice Address - Fax:417-501-1661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1275048324OtherNPPES
MO1376088369OtherNPPES
MO1114279460OtherNPPES
MO1427356989Medicaid
MO182138649Medicaid
MO1649589706OtherNPPES
MO1215241005Medicaid