Provider Demographics
NPI:1891533618
Name:BISHOP, COURTNEY NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:BISHOP
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 MARYLAND AVE APT 507
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2318
Mailing Address - Country:US
Mailing Address - Phone:478-365-7812
Mailing Address - Fax:
Practice Address - Street 1:2229 S 12TH ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-4130
Practice Address - Country:US
Practice Address - Phone:314-771-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024025025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist