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General NPI Number Information
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NPI Number | 1952471351
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Entity Type | Organization
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Legal Business Name | SOUTHWEST ENDODONTICS
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 05/08/2012
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Provider Practice Location Address
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Address Line | 10777 SUNSET OFFICE DR STE 100
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City | SAINT LOUIS
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State | MO
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Zip | 63127-1019
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Country | US
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Telephone | 314-822-2210
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Fax | 314-822-7633
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Provider Business Mailing Address
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Address Line | 10777 SUNSET OFFICE DR STE 100
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City | SAINT LOUIS
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State | MO
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Zip | 63127-1019
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Country | US
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Telephone | 314-822-2210
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Fax | 314-822-7633
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Authorized Official
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Title or Position | BOARD MEMBER
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Name | TIMOTHY P MAHER
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Credential | DDS
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Telephone | 314-822-2210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 015204
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License Number State | MO
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