Healthcare Provider Details

I. General information

NPI: 1871683771
Provider Name (Legal Business Name): NORTHSIDE ORAL SURGERY CNT DONALD M SUGGS DDSPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1259 N KINGSHIGHWAY BLVD
SAINT LOUIS MO
63113-1647
US

IV. Provider business mailing address

1259 N KINGSHIGHWAY BLVD
SAINT LOUIS MO
63113-1647
US

V. Phone/Fax

Practice location:
  • Phone: 314-361-2200
  • Fax: 314-361-3211
Mailing address:
  • Phone: 314-361-2200
  • Fax: 314-361-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number009792
License Number StateMO

VIII. Authorized Official

Name: DR. DONALD M SUGGS
Title or Position: PRESIDENT
Credential: DDS
Phone: 314-361-2200