Healthcare Provider Details

I. General information

NPI: 1104377431
Provider Name (Legal Business Name): SAINT LOUIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

IV. Provider business mailing address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-7336
  • Fax: 314-977-8617
Mailing address:
  • Phone: 314-977-7336
  • Fax: 314-977-8617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2000174326
License Number StateMO

VIII. Authorized Official

Name: DR. DANIEL C STOECKEL
Title or Position: PROGRAM DIRECTOR-PEDIATRIC DENTISTR
Credential: D.D.S.
Phone: 314-977-8517