Healthcare Provider Details

I. General information

NPI: 1174746564
Provider Name (Legal Business Name): GEORGE V DUELLO DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GEORGE V DUELLO DDS,PC

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 SUNSET OFFICE DR SUITE C105
SAINT LOUIS MO
63127-1015
US

IV. Provider business mailing address

309 GREENBRIAR ESTATES DR
SAINT LOUIS MO
63122-3350
US

V. Phone/Fax

Practice location:
  • Phone: 314-965-3271
  • Fax: 314-965-8113
Mailing address:
  • Phone: 314-822-0765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number00598
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: