Healthcare Provider Details

I. General information

NPI: 1952715971
Provider Name (Legal Business Name): LITTLE URBAN SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N KINGSHIGHWAY BLVD STE 2
SAINT LOUIS MO
63113-1408
US

IV. Provider business mailing address

1301 N KINGSHIGHWAY BLVD STE 2
SAINT LOUIS MO
63113-1408
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-1434
  • Fax:
Mailing address:
  • Phone: 314-367-1434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number003732
License Number StateMO

VIII. Authorized Official

Name: TALISA K GLOVER
Title or Position: PRESIDENT
Credential: R.D.H.
Phone: 314-367-1434