Healthcare Provider Details

I. General information

NPI: 1598988909
Provider Name (Legal Business Name): MATTHEW SHELBY SLAVEN D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

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 STE C105
SAINT LOUIS MO
63127-1014
US

IV. Provider business mailing address

238 CEDAR TRAIL DR
BALLWIN MO
63011-2655
US

V. Phone/Fax

Practice location:
  • Phone: 314-965-3271
  • Fax: 314-965-8113
Mailing address:
  • Phone: 636-527-2307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2005014238
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: