Basic Information
| Provider Information | |||||||||
| NPI: | 1134298631 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRANKLIN COUNTY DENTAL NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 S MCKINLEY AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | UNION | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630841800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362398397 | ||||||||
| FaxNumber: | 3633907379 | ||||||||
| Practice Location | |||||||||
| Address1: | 851 E 5TH ST | ||||||||
| Address2: | SUITE 131 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630903135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362398397 | ||||||||
| FaxNumber: | 6363907379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROEBACK | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 6362391717 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MA, NCC, LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.