MEDICARE: HERBST DMD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1528572435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERBST DMD LLC

Provider Business Mailing Address
First Line	:	PO BOX 3189
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13220-3189
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12221 SAINT CHARLES ROCK RD
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2502
Country	:	US
Telephone Number	:	314-656-6615
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTOPHER HERBST
Credential	:
Telephone Number	:	314-656-6615

Provider Enumeration Date	:	11/30/2017
Last Update Date	:	11/30/2017

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