Provider Demographics
NPI:1740627447
Name:CAPITAL DENTISTRY FOR CHILDREN LLC
Entity type:Organization
Organization Name:CAPITAL DENTISTRY FOR CHILDREN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-874-1990
Mailing Address - Street 1:1000 W. NIFONG BLVD., BLDG 6, SUITE 130
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203
Mailing Address - Country:US
Mailing Address - Phone:573-874-1990
Mailing Address - Fax:573-874-1923
Practice Address - Street 1:931 WILDWOOD DR STE 104
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5719
Practice Address - Country:US
Practice Address - Phone:573-874-1990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0160561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty