Healthcare Provider Details

I. General information

NPI: 1700400868
Provider Name (Legal Business Name): STRATER R CROWFOOT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 11/27/2023
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

IV. Provider business mailing address

9912 JAN DR
SAINT LOUIS MO
63123-6912
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8363
  • Fax:
Mailing address:
  • Phone: 801-310-5467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: