Provider Demographics
NPI:1477660108
Name:TALBOTT, CAROL (DDS)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:TALBOTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 LURLYN DR STE A
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2763
Mailing Address - Country:US
Mailing Address - Phone:573-778-0200
Mailing Address - Fax:573-778-0214
Practice Address - Street 1:1611 LURLYN DR STE A
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2763
Practice Address - Country:US
Practice Address - Phone:573-778-0200
Practice Address - Fax:573-778-0214
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0147761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO402435226Medicaid
45-0471411OtherEIN