Healthcare Provider Details

I. General information

NPI: 1366713596
Provider Name (Legal Business Name): FRANK ANTHONY RUNCO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 CRESTWOOD EXECUTIVE CTR
SAINT LOUIS MO
63126-1904
US

IV. Provider business mailing address

64 CRESTWOOD EXECUTIVE CTR
SAINT LOUIS MO
63126-1904
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-0470
  • Fax: 314-843-0438
Mailing address:
  • Phone: 314-843-0470
  • Fax: 314-843-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14387
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: