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General NPI Number Information
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NPI Number | 1134767866
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Entity Type | Individual
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Provider Name | COURTNEY ETHINGTON DMD, MSD
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Gender | Female
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Dates
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Enumeration Date | 12/12/2019
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Last Update Date | 12/12/2019
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Provider Practice Location Address
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Address Line | 4 WEST DR STE 170
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City | CHESTERFIELD
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State | MO
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Zip | 63017-1793
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Country | US
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Telephone | 636-778-9345
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Fax |
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Provider Business Mailing Address
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Address Line | 1109 E LINDEN AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63117-1378
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 019.032433
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 2019043361
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License Number State | MO
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