Healthcare Provider Details

I. General information

NPI: 1417383852
Provider Name (Legal Business Name): CAULKS HILL DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 CAULKS HILL RD
SAINT CHARLES MO
63304-6863
US

IV. Provider business mailing address

1922 EDWARDSVILLE CLUB PLAZA CT
EDWARDSVILLE IL
62025-3717
US

V. Phone/Fax

Practice location:
  • Phone: 636-441-3430
  • Fax:
Mailing address:
  • Phone: 618-248-2038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2000174030
License Number StateMO

VIII. Authorized Official

Name: DAVID GUILBEAULT
Title or Position: DENTIST
Credential: DMD
Phone: 636-441-3430