Healthcare Provider Details

I. General information

NPI: 1487389672
Provider Name (Legal Business Name): GATEWAY LITTLE SMILES OF BALLWIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

956 KEHRS MILL RD
BALLWIN MO
63011-2402
US

IV. Provider business mailing address

956 KEHRS MILL RD
BALLWIN MO
63011-2402
US

V. Phone/Fax

Practice location:
  • Phone: 636-527-2779
  • Fax:
Mailing address:
  • Phone: 636-527-2779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. COREY HASTINGS
Title or Position: MANAGING MEMBER
Credential: DDS
Phone: 314-496-3562