Healthcare Provider Details

I. General information

NPI: 1164083689
Provider Name (Legal Business Name): JENNIFER N KOPP RDH, BHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 HEALTH DEPARTMENT DR
TROY MO
63379
US

IV. Provider business mailing address

#5 HEALTH DEPARTMENT DRIVE
TROY MO
63379
US

V. Phone/Fax

Practice location:
  • Phone: 636-528-6117
  • Fax:
Mailing address:
  • Phone: 636-528-6117
  • Fax: 636-528-8629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2010018540
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: