Healthcare Provider Details

I. General information

NPI: 1699445163
Provider Name (Legal Business Name): ARCHWAY ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 HAMPTON VILLAGE PLZ STE 225
SAINT LOUIS MO
63109-2128
US

IV. Provider business mailing address

16 HAMPTON VILLAGE PLZ STE 225
SAINT LOUIS MO
63109-2128
US

V. Phone/Fax

Practice location:
  • Phone: 314-916-5757
  • Fax: 314-916-5758
Mailing address:
  • Phone: 314-916-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: TYMAN LOVELESS
Title or Position: OWNER
Credential: DMD, MD
Phone: 314-916-5757