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General NPI Number Information
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NPI Number | 1336689660
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Entity Type | Organization
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Legal Business Name | MATT ST GEORGE INC
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Dates
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Enumeration Date | 03/06/2017
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Last Update Date | 03/06/2017
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Provider Practice Location Address
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Address Line | 603 NICHOLS ST
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City | FULTON
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State | MO
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Zip | 65251-2650
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Country | US
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Telephone | 573-642-6904
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Fax | 573-642-7256
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Provider Business Mailing Address
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Address Line | 603 NICHOLS ST
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City | FULTON
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State | MO
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Zip | 65251-2650
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Country | US
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Telephone | 573-642-6904
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Fax | 573-642-7256
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Authorized Official
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Title or Position | OWNER
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Name | MATTHEW ST GEORGE
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Credential | DDS
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Telephone | 573-642-6904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2008014167
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License Number State | MO
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