Healthcare Provider Details

I. General information

NPI: 1669533899
Provider Name (Legal Business Name): THOMAS SAMUEL BOGUSKY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 11/11/2007
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: 636-447-4080
  • Fax: 636-447-5764
Mailing address:
  • Phone: 636-447-4080
  • Fax: 636-447-5764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11038
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: