Healthcare Provider Details

I. General information

NPI: 1790852267
Provider Name (Legal Business Name): TAWANA KIESHAWN WARE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAWANA KIESHAWN LEE DDS

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11709 OLD BALLAS RD SUITE 104
CREVE COEUR MO
63141
US

IV. Provider business mailing address

2050 BLUESTONE DR
SAINT CHARLES MO
63303-5977
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-1122
  • Fax: 314-567-0260
Mailing address:
  • Phone: 636-946-5225
  • Fax: 636-946-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2004018645
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: