Provider Demographics
NPI:1982800850
Name:DAVID L. DETAR, DDS, PC
Entity type:Organization
Organization Name:DAVID L. DETAR, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:DETAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-781-8240
Mailing Address - Street 1:3115 ARIZONA AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3125
Mailing Address - Country:US
Mailing Address - Phone:417-781-8240
Mailing Address - Fax:
Practice Address - Street 1:3115 ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3125
Practice Address - Country:US
Practice Address - Phone:417-781-8240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12028261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental