Provider Demographics
NPI:1538042197
Name:CENTRALIA DENTAL LLC
Entity type:Organization
Organization Name:CENTRALIA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:GARTON
Authorized Official - Last Name:BUESCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-291-1411
Mailing Address - Street 1:110 W SNEED ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65240-1375
Mailing Address - Country:US
Mailing Address - Phone:573-682-5616
Mailing Address - Fax:
Practice Address - Street 1:110 W SNEED ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:MO
Practice Address - Zip Code:65240-1375
Practice Address - Country:US
Practice Address - Phone:573-682-5616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-30
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty