Healthcare Provider Details

I. General information

NPI: 1699484840
Provider Name (Legal Business Name): CALLAWAY FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 N BLUFF ST
FULTON MO
65251-2709
US

IV. Provider business mailing address

2424 N BLUFF ST
FULTON MO
65251-2709
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-6904
  • Fax:
Mailing address:
  • Phone: 573-642-6904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEX MADOV
Title or Position: MEMBER
Credential: DDS
Phone: 402-850-9285