Healthcare Provider Details

I. General information

NPI: 1437249422
Provider Name (Legal Business Name): NIDA LUANGJAMEKORN PALMER D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 MEXICO RD
SAINT PETERS MO
63376-6410
US

IV. Provider business mailing address

4125 MEXICO RD
SAINT PETERS MO
63376-6410
US

V. Phone/Fax

Practice location:
  • Phone: 636-441-6110
  • Fax: 636-447-5764
Mailing address:
  • Phone: 636-441-6110
  • Fax: 636-447-5764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60431
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2008011520
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: