MEDICARE: THEODORE J DEIBEL DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12133	MO

General Provider Information

NPI Number	:	1033108444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORE J DEIBEL DMD

Provider Business Mailing Address
First Line	:	8000 BONHOMME AVE
Second Line	:	SUITE 422
City	:	CLAYTON
State	:	MO
Zip	:	63105-3515
Country	:	US
Telephone Number	:	314-725-6999
Fax Number	:

Provider Business Practice Location Address
First Line	:	8000 BONHOMME AVE
Second Line	:	SUITE 422
City	:	CLAYTON
State	:	MO
Zip	:	63105-3515
Country	:	US
Telephone Number	:	314-725-6999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	07/08/2007

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