Provider Demographics
NPI:1740275593
Name:AUTRY, DANIEL M (DMD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:M
Last Name:AUTRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8141 JOHN MCKEEVER RD
Mailing Address - Street 2:
Mailing Address - City:HOUSE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63051-3216
Mailing Address - Country:US
Mailing Address - Phone:618-967-9570
Mailing Address - Fax:
Practice Address - Street 1:8141 JOHN MCKEEVER RD
Practice Address - Street 2:
Practice Address - City:HOUSE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:63051-3216
Practice Address - Country:US
Practice Address - Phone:618-967-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86131223P0221X
MO20050197701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry