Healthcare Provider Details

I. General information

NPI: 1780797308
Provider Name (Legal Business Name): JACK M. MARINCEL, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6060 TELEGRAPH RD SUITE H
SAINT LOUIS MO
63129-4762
US

IV. Provider business mailing address

6060 TELEGRAPH RD SUITE H
SAINT LOUIS MO
63129-4762
US

V. Phone/Fax

Practice location:
  • Phone: 314-846-1480
  • Fax:
Mailing address:
  • Phone: 314-846-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number13331
License Number StateMO

VIII. Authorized Official

Name: DR. JOHN MICHAEL MARINCEL
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 314-846-1480