Healthcare Provider Details

I. General information

NPI: 1376472258
Provider Name (Legal Business Name): DEVIN EUGENE WIDICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

IV. Provider business mailing address

1518 MOCKINGBIRD LN
WEATHERFORD OK
73096-2738
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8363
  • Fax:
Mailing address:
  • Phone: 580-334-9423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8224
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: