Healthcare Provider Details

I. General information

NPI: 1043899677
Provider Name (Legal Business Name): RIVER CITY ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 12/12/2021
Certification Date: 12/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CHURCH ST
O FALLON MO
63366-2894
US

IV. Provider business mailing address

113 CHURCH ST
O FALLON MO
63366-2894
US

V. Phone/Fax

Practice location:
  • Phone: 636-362-4040
  • Fax: 636-362-4141
Mailing address:
  • Phone: 636-362-4040
  • Fax: 636-362-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW JAMES WALKER
Title or Position: OWNER
Credential: D.D.S., M.S.D
Phone: 636-362-4040