Healthcare Provider Details

I. General information

NPI: 1467584854
Provider Name (Legal Business Name): DAVID A. DURHAM DDS AND ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 WATSON RD SUITE A
SAINT LOUIS MO
63126-1854
US

IV. Provider business mailing address

10000 WATSON RD SUITE A
SAINT LOUIS MO
63126-1854
US

V. Phone/Fax

Practice location:
  • Phone: 314-822-3322
  • Fax: 314-822-0537
Mailing address:
  • Phone: 314-822-3322
  • Fax: 314-822-0537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14054
License Number StateMO

VIII. Authorized Official

Name: DR. GREGG WILLIAM HOSCH
Title or Position: PRESIDENT
Credential: DDS
Phone: 314-822-3322