Healthcare Provider Details

I. General information

NPI: 1912019290
Provider Name (Legal Business Name): DAVID M IVEY DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE MID RIVERS MALL DR STE 310
ST PETERS MO
63376-4323
US

IV. Provider business mailing address

ONE MID RIVERS MALL DR STE 310
ST PETERS MO
63376-4323
US

V. Phone/Fax

Practice location:
  • Phone: 636-928-7217
  • Fax: 636-397-1137
Mailing address:
  • Phone: 636-928-7217
  • Fax: 636-397-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number012332
License Number StateMO

VIII. Authorized Official

Name: DAVID M IVEY
Title or Position: PRESIDENT
Credential: DDS
Phone: 636-928-7217