Healthcare Provider Details

I. General information

NPI: 1386242832
Provider Name (Legal Business Name): BRENDA PUMMILL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA NAYLOR

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W WORLEY ST
COLUMBIA MO
65203-2037
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 844-853-8937
  • Fax:
Mailing address:
  • Phone: 660-885-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2005015895
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: