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General NPI Number Information
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NPI Number | 1780134569
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Entity Type | Organization
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Legal Business Name | JACK D. GRIFFIN, JR. D.M.D., LAKE ST. LOUIS, LLC
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Dates
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Enumeration Date | 10/05/2016
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Last Update Date | 10/05/2016
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Provider Practice Location Address
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Address Line | 1000 LAKE SAINT LOUIS BLVD
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City | LAKE ST LOUIS
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State | MO
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Zip | 63367-1340
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Country | US
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Telephone | 314-488-1201
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Fax |
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Provider Business Mailing Address
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Address Line | 336 BARN SIDE LN
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City | EUREKA
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State | MO
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Zip | 63025-1650
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JACK GRIFFIN JR.
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Credential | DMD
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Telephone | 314-488-1201
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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 | 014900
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License Number State | MO
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