Healthcare Provider Details

I. General information

NPI: 1649445321
Provider Name (Legal Business Name): TRI-COUNTY ORTHODONTICS, ASSOCIATES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 WASHINGTON SQUARE SHOPPING CTR STE G
WASHINGTON MO
63090-5307
US

IV. Provider business mailing address

1015-G WASHINGTON SQUARE SHOPPING CENTER
WASHINGTON MO
63090
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-4004
  • Fax: 636-239-6576
Mailing address:
  • Phone: 636-239-4004
  • Fax: 636-239-6576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDE015380
License Number StateMO

VIII. Authorized Official

Name: DR. JACQUELINE M. MILLER
Title or Position: ORTHODONTIST
Credential: DDS, MS
Phone: 636-239-4004