Healthcare Provider Details

I. General information

NPI: 1578729133
Provider Name (Legal Business Name): GREGORY L STINE JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W NIFONG BLVD BUILDING 6, SUITE 130
COLUMBIA MO
65203-5615
US

IV. Provider business mailing address

1000 W NIFONG BLVD BUILDING 6, SUITE 130
COLUMBIA MO
65203-5615
US

V. Phone/Fax

Practice location:
  • Phone: 573-874-1990
  • Fax: 573-874-1923
Mailing address:
  • Phone: 573-874-1990
  • Fax: 573-874-1923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number016119
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: