Provider Demographics
NPI:1164039558
Name:JON COPELAND DDS LLC
Entity Type:Organization
Organization Name:JON COPELAND DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRISTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAMPLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-273-5866
Mailing Address - Street 1:2426 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1222
Mailing Address - Country:US
Mailing Address - Phone:636-273-5866
Mailing Address - Fax:
Practice Address - Street 1:2426 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1222
Practice Address - Country:US
Practice Address - Phone:636-273-5866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental