Provider Demographics
NPI:1457551483
Name:MCCOY SAMPLES MATTINGLY DENTAL CLINIC
Entity Type:Organization
Organization Name:MCCOY SAMPLES MATTINGLY DENTAL CLINIC
Other - Org Name:MCCOY DENTAL CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLFE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:660-646-3802
Mailing Address - Street 1:850 FAIRWAY DR
Mailing Address - Street 2:PO BOX 1167
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601
Practice Address - Country:US
Practice Address - Phone:660-646-3802
Practice Address - Fax:660-646-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty