Healthcare Provider Details

I. General information

NPI: 1801508379
Provider Name (Legal Business Name): MISSOURI CENTER FOR ORAL SURGERY AND IMPLANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MID RIVERS MALL DR STE 310
SAINT PETERS MO
63376-4323
US

IV. Provider business mailing address

1 MID RIVERS MALL DR STE 310
SAINT PETERS MO
63376-4323
US

V. Phone/Fax

Practice location:
  • Phone: 636-928-7217
  • Fax: 636-397-0223
Mailing address:
  • Phone: 636-928-7217
  • Fax: 636-397-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. KELSEY CAITLIN SMITH
Title or Position: PARTNER
Credential: DDS, MD
Phone: 314-956-5651