MEDICARE: SCENIC DRIVE DENTAL CENTER

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

General Provider Information

NPI Number	:	1134397680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCENIC DRIVE DENTAL CENTER

Provider Business Mailing Address
First Line	:	PO BOX 337
Second Line	:	1171 SCENIC DRIVE
City	:	HERCULANEUM
State	:	MO
Zip	:	63048-0337
Country	:	US
Telephone Number	:	636-479-5324
Fax Number	:

Provider Business Practice Location Address
First Line	:	1171 SCENIC DR
Second Line	:
City	:	HERCULANEUM
State	:	MO
Zip	:	63048-0337
Country	:	US
Telephone Number	:	636-479-5324
Fax Number	:

Authorized Official
Title or Position	:	DENTIST, OWNER
Name	:	MRS. JOSEPH L SCHMIEDER
Credential	:	DMD
Telephone Number	:	636-479-5324

Provider Enumeration Date	:	02/19/2008
Last Update Date	:	02/19/2008

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