=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346394970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATEWAY ORAL HEALTH FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9378 OLIVE ST STE ILL GATEWAY ORAL HEALTH FOUNDATION
-----------------------------------------------------
City | OLIVETTE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-9378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-872-3930
-----------------------------------------------------
Fax | 314-872-3952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9378 OLIVE ST STE ILL
-----------------------------------------------------
City | OLIVETTE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-9378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-872-3930
-----------------------------------------------------
Fax | 314-872-3952
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. BYRON V DEVALL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 314-872-3930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | M0013419
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------