Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 2002012097 | MO |
N | 1223D0001X | Dental Public Health | 3693 | AR |
NPI | 1053467399 |
---|---|
Provider Name | Dr. Craig Allen Rechkemmer |
First Address | Ozark, MO 65721-7997 |
Second Address | Springfield, MO 65810-1724 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2007 |
Last Update Date | 17/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2002012097 | MISSOURI DENTAL BOARD (01) | MO |
3693 | ARKANSAS DENTAL BOARD (01) | AR |
405744707 | (05) | MO |