MEDICARE: CHARLES E. NIESEN II, DMD, MICHAEL J. FADDIS, DDS

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	:	1548321318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES E. NIESEN II, DMD, MICHAEL J. FADDIS, DDS

Provider Business Mailing Address
First Line	:	2440 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2321
Country	:	US
Telephone Number	:	314-962-6643
Fax Number	:	314-962-2205

Provider Business Practice Location Address
First Line	:	2440 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2321
Country	:	US
Telephone Number	:	314-962-6643
Fax Number	:	314-962-2205

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL J. FADDIS
Credential	:	DDS
Telephone Number	:	314-962-6643

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	08/21/2007

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