Healthcare Provider Details

I. General information

NPI: 1649327057
Provider Name (Legal Business Name): THOMAS V. SCHABERG D.D.S. M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 WESTPORT PLZ SUITE 367
SAINT LOUIS MO
63146-3107
US

IV. Provider business mailing address

77 WESTPORT PLZ SUITE 367
SAINT LOUIS MO
63146-3107
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-4676
  • Fax: 314-434-6806
Mailing address:
  • Phone: 314-434-4676
  • Fax: 314-434-6806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number13156
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: