=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558578187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRY EGAN DDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12758 BOENKER LN
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63044-2436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-739-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15728 TRAPP RIDGE CT
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-8742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. TERRY R EGAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 314-739-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 014516
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------