Healthcare Provider Details

I. General information

NPI: 1700151768
Provider Name (Legal Business Name): COLUMBIA DENTISTRY FOR CHILDREN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W NIFONG BLVD STE 6-130
COLUMBIA MO
65203-5607
US

IV. Provider business mailing address

1000 W NIFONG BLVD STE 6-130
COLUMBIA MO
65203-5607
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 NumberLC1018573
License Number StateMO

VIII. Authorized Official

Name: DR. ROBERT COYLE
Title or Position: OWNER
Credential: DDS
Phone: 573-874-1990