Healthcare Provider Details

I. General information

NPI: 1346394970
Provider Name (Legal Business Name): GATEWAY ORAL HEALTH FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9378 OLIVE ST STE ILL GATEWAY ORAL HEALTH FOUNDATION
OLIVETTE MO
63132-9378
US

IV. Provider business mailing address

9378 OLIVE ST STE ILL
OLIVETTE MO
63132-9378
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-3930
  • Fax: 314-872-3952
Mailing address:
  • Phone: 314-872-3930
  • Fax: 314-872-3952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM0013419
License Number StateMO

VIII. Authorized Official

Name: DR. BYRON V DEVALL
Title or Position: DENTIST
Credential: DDS
Phone: 314-872-3930