Healthcare Provider Details

I. General information

NPI: 1093064057
Provider Name (Legal Business Name): ST. LOUIS SURGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 GINGER CREEK PKWY
GLEN CARBON IL
62034-3502
US

IV. Provider business mailing address

24 GINGER CREEK PKWY
GLEN CARBON IL
62034-3502
US

V. Phone/Fax

Practice location:
  • Phone: 618-655-1580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number19025397
License Number StateIL

VIII. Authorized Official

Name: DAVID GUILBEAULT
Title or Position: OWNER
Credential: DMD
Phone: 618-643-9523