Healthcare Provider Details

I. General information

NPI: 1568669349
Provider Name (Legal Business Name): WYDOWN DENTAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S HANLEY RD
SAINT LOUIS MO
63105-2038
US

IV. Provider business mailing address

510 S HANLEY RD
SAINT LOUIS MO
63105-2038
US

V. Phone/Fax

Practice location:
  • Phone: 314-721-2346
  • Fax:
Mailing address:
  • Phone: 314-721-2346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. JAN H ROGERS
Title or Position: OWNER
Credential: DMD
Phone: 314-721-2346