Healthcare Provider Details

I. General information

NPI: 1285092320
Provider Name (Legal Business Name): COREY HASTINGS DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 02/01/2020
Certification Date: 02/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104
US

IV. Provider business mailing address

14 BRIARWICK TRL
SAINT PETERS MO
63376-3370
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8363
  • Fax:
Mailing address:
  • Phone: 314-496-3562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30024956
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2018004249
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2018004249
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: