Healthcare Provider Details

I. General information

NPI: 1033809181
Provider Name (Legal Business Name): ALLY MARIE GOURLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

IV. Provider business mailing address

4028 NW CLAYMONT DR
KANSAS CITY MO
64116-1751
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-7336
  • Fax:
Mailing address:
  • Phone: 785-562-6235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2026026685
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: