Healthcare Provider Details

I. General information

NPI: 1740275593
Provider Name (Legal Business Name): DANIEL M AUTRY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8141 JOHN MCKEEVER RD
HOUSE SPRINGS MO
63051-3216
US

IV. Provider business mailing address

8141 JOHN MCKEEVER RD
HOUSE SPRINGS MO
63051-3216
US

V. Phone/Fax

Practice location:
  • Phone: 618-967-9570
  • Fax:
Mailing address:
  • Phone: 618-967-9570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8613
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2005019770
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: