Healthcare Provider Details

I. General information

NPI: 1356331672
Provider Name (Legal Business Name): MICHAEL W NOBLE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 W MAIN ST
BELLEVILLE IL
62223-1408
US

IV. Provider business mailing address

10200 W MAIN ST
BELLEVILLE IL
62223-1408
US

V. Phone/Fax

Practice location:
  • Phone: 618-397-2464
  • Fax: 618-398-4450
Mailing address:
  • Phone: 618-400-6725
  • Fax: 618-500-6725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14929
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019019361
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: