Healthcare Provider Details

I. General information

NPI: 1063527604
Provider Name (Legal Business Name): WILLIAM L MASTORAKOS DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

10115 MANCHESTER RD STE 200
ST LOUIS MO
63122
US

IV. Provider business mailing address

10115 MANCHESTER RD STE 200
ST LOUIS MO
63122
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-4117
  • Fax: 314-966-8630
Mailing address:
  • Phone: 314-966-4117
  • Fax: 314-966-8630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number013600
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: