Healthcare Provider Details

I. General information

NPI: 1952702821
Provider Name (Legal Business Name): LA CROSS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11634 W FLORISSANT AVE
FLORISSANT MO
63033-6723
US

IV. Provider business mailing address

11634 W FLORISSANT AVE
FLORISSANT MO
63033-6723
US

V. Phone/Fax

Practice location:
  • Phone: 314-322-4719
  • Fax: 314-837-9778
Mailing address:
  • Phone: 314-322-4719
  • Fax: 314-837-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2013030663
License Number StateMO

VIII. Authorized Official

Name: DR. DAVID GUILBEAULT
Title or Position: OWNER
Credential: DMD
Phone: 618-692-1110