Healthcare Provider Details

I. General information

NPI: 1528100344
Provider Name (Legal Business Name): EDMOND RAINEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14390 WOODLAKE DR
CHESTERFIELD MO
63017-5714
US

IV. Provider business mailing address

14390 WOODLAKE DR
CHESTERFIELD MO
63017-5714
US

V. Phone/Fax

Practice location:
  • Phone: 314-576-6500
  • Fax: 314-576-5802
Mailing address:
  • Phone: 314-576-6500
  • Fax: 314-576-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number012015
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: