Healthcare Provider Details

I. General information

NPI: 1306630751
Provider Name (Legal Business Name): COURTNEY T MIETZ DMD MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3890 S LINDBERGH BLVD STE 115
SAINT LOUIS MO
63127-1391
US

IV. Provider business mailing address

3890 S LINDBERGH BLVD STE 115
SAINT LOUIS MO
63127-1391
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-5553
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2025004576
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: