Provider Demographics
NPI:1003929969
Name:LUTTERBIE, VINCENT MILES (DDS)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:MILES
Last Name:LUTTERBIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340
Mailing Address - Country:US
Mailing Address - Phone:660-886-2202
Mailing Address - Fax:660-886-3047
Practice Address - Street 1:LINCOLN AND SLATER STREETS
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340
Practice Address - Country:US
Practice Address - Phone:660-886-2202
Practice Address - Fax:660-886-3047
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0013387122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8140613OtherCPIN
8140613Medicare ID - Type Unspecified
8140613OtherCPIN