Provider Demographics
NPI:1164959524
Name:COTTON, MARIEL
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:COTTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 GREENFIELD PL APT 311
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7299
Mailing Address - Country:US
Mailing Address - Phone:815-540-7711
Mailing Address - Fax:
Practice Address - Street 1:840 ADMIRAL WEINEL BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1992
Practice Address - Country:US
Practice Address - Phone:618-281-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170050191223X0400X
IL0210027981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics