MEDICARE: CAPITAL DENTISTRY FOR CHILDREN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	016056	MO

General Provider Information

NPI Number	:	1740627447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITAL DENTISTRY FOR CHILDREN LLC

Provider Business Mailing Address
First Line	:	1000 W. NIFONG BLVD., BLDG 6, SUITE 130
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203
Country	:	US
Telephone Number	:	573-874-1990
Fax Number	:	573-874-1923

Provider Business Practice Location Address
First Line	:	931 WILDWOOD DR STE 104
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-5719
Country	:	US
Telephone Number	:	573-874-1990
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	DR. ROBERT DALE COYLE
Credential	:	DDS
Telephone Number	:	573-874-1990

Provider Enumeration Date	:	06/04/2013
Last Update Date	:	06/04/2013

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