Healthcare Provider Details

I. General information

NPI: 1811985088
Provider Name (Legal Business Name): DOUGLAS HARRY REDIGER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3876 VOGEL RD
ARNOLD MO
63010-3776
US

IV. Provider business mailing address

3876 VOGEL RD
ARNOLD MO
63010-3776
US

V. Phone/Fax

Practice location:
  • Phone: 636-282-0550
  • Fax: 636-282-1011
Mailing address:
  • Phone: 636-282-0550
  • Fax: 636-282-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0115501
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: