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General NPI Number Information
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NPI Number | 1164959524
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Entity Type | Individual
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Provider Name | MARIEL COTTON
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Gender | Female
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Dates
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Enumeration Date | 05/16/2017
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Last Update Date | 05/16/2017
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Provider Practice Location Address
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Address Line | 840 ADMIRAL WEINEL BLVD
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City | COLUMBIA
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State | IL
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Zip | 62236-1992
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Country | US
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Telephone | 618-281-2929
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Fax |
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Provider Business Mailing Address
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Address Line | 1224 GREENFIELD PL APT 311
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City | O FALLON
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State | IL
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Zip | 62269-7299
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Country | US
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Telephone | 815-540-7711
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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 | 2017005019
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 021002798
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License Number State | IL
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