Healthcare Provider Details

I. General information

NPI: 1396369757
Provider Name (Legal Business Name): JAMIE CAROLINA TERRILL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 10/14/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10049 MANCHESTER RD
SAINT LOUIS MO
63122-1825
US

IV. Provider business mailing address

10049 MANCHESTER RD
SAINT LOUIS MO
63122-1825
US

V. Phone/Fax

Practice location:
  • Phone: 314-671-4019
  • Fax: 314-671-4018
Mailing address:
  • Phone: 314-671-4019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2020026051
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: