Healthcare Provider Details

I. General information

NPI: 1295964104
Provider Name (Legal Business Name): ALL STAR DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2009
Last Update Date: 07/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201A E 5TH ST
EUREKA MO
63025-1223
US

IV. Provider business mailing address

201A E 5TH ST
EUREKA MO
63025-1223
US

V. Phone/Fax

Practice location:
  • Phone: 636-938-7827
  • Fax: 636-938-5979
Mailing address:
  • Phone: 636-938-7827
  • Fax: 636-938-5979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2002007232
License Number StateMO

VIII. Authorized Official

Name: ARTHUR T ENGELAGE
Title or Position: OWNER
Credential: DMD
Phone: 618-233-3503