Healthcare Provider Details

I. General information

NPI: 1407349210
Provider Name (Legal Business Name): MICHAEL CHARLES CRIPPEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E 10TH ST
ROLLA MO
65401-4603
US

IV. Provider business mailing address

1810 E 10TH ST
ROLLA MO
65401-4603
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-1821
  • Fax:
Mailing address:
  • Phone: 573-364-1821
  • Fax: 573-362-3645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2020009632
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: