Healthcare Provider Details

I. General information

NPI: 1417218249
Provider Name (Legal Business Name): SOUTHWEST ENDODONTIC ASSOC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6651 CHIPPEWA SUITE 323
ST. LOUIS MO
63109
US

IV. Provider business mailing address

6651 CHIPPEWA STE 323
ST. LOUIS MO
63109
US

V. Phone/Fax

Practice location:
  • Phone: 314-781-1919
  • Fax: 314-781-0880
Mailing address:
  • Phone: 314-781-1919
  • Fax: 314-781-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number14082
License Number StateMD

VIII. Authorized Official

Name: DR. GILBERT J CYR
Title or Position: OWNER
Credential: D.D.S.
Phone: 314-781-1919