Healthcare Provider Details

I. General information

NPI: 1730236894
Provider Name (Legal Business Name): ACCENT DENTAL CENTER ON FORUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 FORUM BLVD STE. 203
COLUMBIA MO
65203-1915
US

IV. Provider business mailing address

1401 FORUM BLVD STE. 203
COLUMBIA MO
65203-1915
US

V. Phone/Fax

Practice location:
  • Phone: 573-446-7181
  • Fax: 573-446-1770
Mailing address:
  • Phone: 573-446-7181
  • Fax: 573-446-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2003011293
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number010435
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. HEATHER R. BURTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-446-7181