Healthcare Provider Details

I. General information

NPI: 1467693630
Provider Name (Legal Business Name): SCHAFFER AND DITTO DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 CUNNINGHAM AVE
JOPLIN MO
64804-1542
US

IV. Provider business mailing address

2602 CUNNINGHAM AVE
JOPLIN MO
64804-1542
US

V. Phone/Fax

Practice location:
  • Phone: 417-623-2000
  • Fax: 417-623-7948
Mailing address:
  • Phone: 417-623-2000
  • Fax: 417-623-7948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11810
License Number StateMO

VIII. Authorized Official

Name: SHANA HOLMAN
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 417-623-2000