Provider Demographics
NPI:1730236894
Name:ACCENT DENTAL CENTER ON FORUM, LLC
Entity type:Organization
Organization Name:ACCENT DENTAL CENTER ON FORUM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:R
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-446-7181
Mailing Address - Street 1:1401 FORUM BLVD
Mailing Address - Street 2:STE. 203
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1915
Mailing Address - Country:US
Mailing Address - Phone:573-446-7181
Mailing Address - Fax:573-446-1770
Practice Address - Street 1:1401 FORUM BLVD
Practice Address - Street 2:STE. 203
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-1915
Practice Address - Country:US
Practice Address - Phone:573-446-7181
Practice Address - Fax:573-446-1770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003011293122300000X
MO0104351223P0221X
1223X2210X, 332B00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X2210XDental ProvidersDentistOrofacial PainGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty