Healthcare Provider Details

I. General information

NPI: 1942751086
Provider Name (Legal Business Name): CHERRY HILL DENTAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 S COUNTRY CLUB DR
JEFFERSON CITY MO
65109-0352
US

IV. Provider business mailing address

220 DIEGO DR STE 201
COLUMBIA MO
65203-4923
US

V. Phone/Fax

Practice location:
  • Phone: 573-556-8500
  • Fax:
Mailing address:
  • Phone: 573-356-9967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2000158124
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number2000158124
License Number StateMO

VIII. Authorized Official

Name: DR. MARY VIRGINIA GADBOIS
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 573-446-0880