MEDICARE: DR. WOODY SOONATTRAKUL 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	122300000X	Dentist	019.027241	IL
2	122300000X	Dentist	2007006450	MO

General Provider Information

NPI Number	:	1609023977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WOODY SOONATTRAKUL DDS

Provider Business Mailing Address
First Line	:	1610 MISSISSIPPI AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2549
Country	:	US
Telephone Number	:	314-602-0019
Fax Number	:

Provider Business Practice Location Address
First Line	:	1610 MISSISSIPPI AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2549
Country	:	US
Telephone Number	:	314-602-0019
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2008
Last Update Date	:	10/15/2014

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