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General NPI Number Information
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NPI Number | 1336314079
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Entity Type | Organization
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Legal Business Name | STEPHEN W. HIATT DDS AND MARYANN L. UDY DMD PC
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Dates
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Enumeration Date | 04/24/2008
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Last Update Date | 06/28/2019
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Provider Practice Location Address
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Address Line | 2992 HIGHWAY K STE 133
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City | O FALLON
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State | MO
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Zip | 63368-7861
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Country | US
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Telephone | 636-978-6967
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Fax | 636-978-5905
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Provider Business Mailing Address
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Address Line | 5551 WINGHAVEN BLVD. STE. 210
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City | O'FALLON
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State | MO
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Zip | 63368
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Country | US
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Telephone | 636-978-6967
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Fax | 636-978-5905
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MRS. LANA S. WISNIEWSKI
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Credential |
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Telephone | 636-978-6967
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 011813
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License Number State | MO
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