Healthcare Provider Details

I. General information

NPI: 1700193869
Provider Name (Legal Business Name): GREGORY J POWELL DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DEPAUL DRIVE STE 885
BRIDGETON MO
63044
US

IV. Provider business mailing address

12255 DEPAUL DRIVE STE 885
BRIDGETON MO
63044
US

V. Phone/Fax

Practice location:
  • Phone: 314-298-0727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12148
License Number StateMO

VIII. Authorized Official

Name: DR. GREGORY J POWELL
Title or Position: PRESIDENT
Credential: DMD
Phone: 314-298-0727