Healthcare Provider Details

I. General information

NPI: 1891851515
Provider Name (Legal Business Name): DR SUSAN ADAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15421 CLAYTON RD STE 102
BALLWIN MO
63011-3161
US

IV. Provider business mailing address

15421 CLAYTON RD STE 102
BALLWIN MO
63011-3161
US

V. Phone/Fax

Practice location:
  • Phone: 636-391-8080
  • Fax: 636-391-2266
Mailing address:
  • Phone: 636-391-8080
  • Fax: 636-391-2266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number015628
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SUSAN ADAMS
Title or Position: DOCTOR
Credential: DMD
Phone: 636-391-8080