Healthcare Provider Details

I. General information

NPI: 1669110599
Provider Name (Legal Business Name): JACK GUO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CHURCH ST
O FALLON MO
63366-2894
US

IV. Provider business mailing address

2220 MID RIVERS PLACE DR APT 2220
SAINT PETERS MO
63304-4438
US

V. Phone/Fax

Practice location:
  • Phone: 636-362-4040
  • Fax:
Mailing address:
  • Phone: 870-404-8258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2024015466
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: