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General NPI Number Information
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NPI Number | 1972706158
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Entity Type | Individual
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Provider Name | HARRY JEROME FONDREN D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 7645 DELMAR BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63130-3910
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Country | US
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Telephone | 314-727-6323
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Fax | 314-727-9263
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Provider Business Mailing Address
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Address Line | 7645 DELMAR BLVD.
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City | SAINT LOUIS
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State | MO
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Zip | 63130
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Country | US
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Telephone | 314-727-6323
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Fax | 314-727-9263
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 12216
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License Number State | MO
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