Basic Information
| Provider Information | |||||||||
| NPI: | 1740841907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRATZ | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEARMAN | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1320 COLUMBIA CENTER DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187192400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 33 GAGE DR | ||||||||
| Address2: | |||||||||
| City: | HOLLISTER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656725862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173348300 | ||||||||
| FaxNumber: | 4173348384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2019 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2019021343 | MO | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 2019021343 | 01 | MO | MISSOURI PROFESSIONAL LICENSE | OTHER |