Healthcare Provider Details

I. General information

NPI: 1235197724
Provider Name (Legal Business Name): CARROLLTON DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411A N JEFFERSON ST
CARROLLTON MO
64633-1945
US

IV. Provider business mailing address

1411A N JEFFERSON ST
CARROLLTON MO
64633-1945
US

V. Phone/Fax

Practice location:
  • Phone: 660-542-1653
  • Fax: 660-542-1654
Mailing address:
  • Phone: 660-542-1653
  • Fax: 660-542-1654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MRS. VICKI L NOLKE
Title or Position: OFFICE MANAGER
Credential:
Phone: 660-542-1653