Healthcare Provider Details

I. General information

NPI: 1427221688
Provider Name (Legal Business Name): DUANE A DILWORTH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6121 N HANLEY RD
SAINT LOUIS MO
63134-2003
US

IV. Provider business mailing address

6121 N HANLEY RD
SAINT LOUIS MO
63134-2003
US

V. Phone/Fax

Practice location:
  • Phone: 314-615-0877
  • Fax: 314-615-8303
Mailing address:
  • Phone: 314-615-0877
  • Fax: 314-615-8303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number014675
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number014675
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: