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General NPI Number Information
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NPI Number | 1982918884
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Entity Type | Organization
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Legal Business Name | MATCHSTICK LLC
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Dates
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Enumeration Date | 08/03/2010
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Last Update Date | 08/03/2010
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Provider Practice Location Address
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Address Line | 2401 BERNADETTE DR SUITE 217
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City | COLUMBIA
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State | MO
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Zip | 65203-4672
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Country | US
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Telephone | 573-445-1100
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Fax | 573-445-1153
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Provider Business Mailing Address
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Address Line | 3600 VAWTER SCHOOL RD
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City | COLUMBIA
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State | MO
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Zip | 65203-9418
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Country | US
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Telephone | 573-445-1100
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Fax | 573-445-1153
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | DR. MARY VIRGINIA GADBOIS
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Credential | DDS
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Telephone | 573-446-0880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2009013643
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License Number State | MO
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