Healthcare Provider Details

I. General information

NPI: 1164622395
Provider Name (Legal Business Name): WALTER R. PFITZINGER D.D.S,, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 VANDIVER DR SUITE 104
COLUMBIA MO
65202-3932
US

IV. Provider business mailing address

1500 VANDIVER DR SUITE 104
COLUMBIA MO
65202-3932
US

V. Phone/Fax

Practice location:
  • Phone: 573-814-1694
  • Fax: 573-814-2845
Mailing address:
  • Phone: 573-814-1694
  • Fax: 573-814-2845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number010435
License Number StateMO

VIII. Authorized Official

Name: MRS. KERRI L SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-814-1694