MEDICARE: DR. MICHAEL FADDIS DDS

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	1223G0001X	General Practice Dentistry	013100	MO

General Provider Information

NPI Number	:	1114088036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL FADDIS DDS

Provider Business Mailing Address
First Line	:	2440 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2321
Country	:	US
Telephone Number	:	314-962-6643
Fax Number	:	314-962-2205

Provider Business Practice Location Address
First Line	:	2440 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2321
Country	:	US
Telephone Number	:	314-962-6643
Fax Number	:	314-962-2205

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	07/08/2007

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