Healthcare Provider Details

I. General information

NPI: 1952471351
Provider Name (Legal Business Name): SOUTHWEST ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10777 SUNSET OFFICE DR STE 100
SAINT LOUIS MO
63127-1019
US

IV. Provider business mailing address

10777 SUNSET OFFICE DR STE 100
SAINT LOUIS MO
63127-1019
US

V. Phone/Fax

Practice location:
  • Phone: 314-822-2210
  • Fax: 314-822-7633
Mailing address:
  • Phone: 314-822-2210
  • Fax: 314-822-7633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number015204
License Number StateMO

VIII. Authorized Official

Name: TIMOTHY P MAHER
Title or Position: BOARD MEMBER
Credential: DDS
Phone: 314-822-2210