=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740277540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD RAYMOND MAINHURST DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2005
-----------------------------------------------------
Last Update Date | 01/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2647 LOCUST ST
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63103-1411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-751-8879
-----------------------------------------------------
Fax | 833-529-0574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 18412
-----------------------------------------------------
City | PALATINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60055-8412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-525-5484
-----------------------------------------------------
Fax | 833-394-4961
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 014599
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------