Healthcare Provider Details

I. General information

NPI: 1427315431
Provider Name (Legal Business Name): MICHAEL J BACKER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2012
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17300 OUTER 40 RD N. SUITE 103
CHESTERFIELD MO
63005
US

IV. Provider business mailing address

17300 OUTER 40 RD N. SUITE 103
CHESTERFIELD MO
63005
US

V. Phone/Fax

Practice location:
  • Phone: 636-536-5158
  • Fax: 636-536-4544
Mailing address:
  • Phone: 636-536-5158
  • Fax: 636-536-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2016006250
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: