Healthcare Provider Details

I. General information

NPI: 1912966896
Provider Name (Legal Business Name): PETER JOHN DURSO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11810 GRAVOIS
ST LOUIS MO
63127
US

IV. Provider business mailing address

11810 GRAVOIS SUITE 104
ST LOUIS MO
63127
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-5000
  • Fax:
Mailing address:
  • Phone: 314-842-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number011726
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: