MEDICARE: WASHINGTON SQUARE DENTAL

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	2004013254	MO

General Provider Information

NPI Number	:	1891987954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON SQUARE DENTAL

Provider Business Mailing Address
First Line	:	1015 WASHINGTON SQ STE E
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-5307
Country	:	US
Telephone Number	:	636-239-7828
Fax Number	:	636-239-5048

Provider Business Practice Location Address
First Line	:	1015 WASHINGTON SQ STE E
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-5307
Country	:	US
Telephone Number	:	636-239-7828
Fax Number	:	636-239-5048

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MELISSA ANN SMITH
Credential	:	D.D.S, P.C.
Telephone Number	:	636-239-7828

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	08/13/2007

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Directions to “WASHINGTON SQUARE DENTAL ” Practice Location

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