Healthcare Provider Details

I. General information

NPI: 1538661087
Provider Name (Legal Business Name): SOH OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 OFALLON RD # I
WELDON SPRING MO
63304-8102
US

IV. Provider business mailing address

810 OFALLON RD # I
WELDON SPRING MO
63304-8102
US

V. Phone/Fax

Practice location:
  • Phone: 314-753-8154
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ASHLY SUNSHINE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 314-413-2803