Provider Demographics
NPI:1427166438
Name:DUFF, CARLA CARISA (DDS)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:CARISA
Last Name:DUFF
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:COLQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1251 E SUNSHINE ST STE 108
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1162
Mailing Address - Country:US
Mailing Address - Phone:417-501-8601
Mailing Address - Fax:417-501-8602
Practice Address - Street 1:1251 E SUNSHINE ST STE 108
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1162
Practice Address - Country:US
Practice Address - Phone:417-501-8601
Practice Address - Fax:417-501-8602
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004018067122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO401030804Medicaid