Healthcare Provider Details

I. General information

NPI: 1932101896
Provider Name (Legal Business Name): MARY ELEANOR THOMAS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MARY ELEANOR CRUMBLEY RDH

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

IV. Provider business mailing address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-5820
  • Fax: 314-367-7010
Mailing address:
  • Phone: 314-367-5820
  • Fax: 314-367-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number001847
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: