Provider Demographics
NPI:1851847131
Name:VINE, DEBRA L
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:VINE
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 1:12720 KANSAS AVE
Mailing Address - Street 2:720
Mailing Address - City:FT. LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473
Mailing Address - Country:US
Mailing Address - Phone:573-596-1470
Mailing Address - Fax:573-596-1482
Practice Address - Street 1:12720 KANSAS AVE
Practice Address - Street 2:BLDG 789
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473
Practice Address - Country:US
Practice Address - Phone:573-596-1470
Practice Address - Fax:573-596-1482
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant