MEDICARE: WEBSTER GROVES ORTHODONTICS LTD

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry		MO

General Provider Information

NPI Number	:	1205251949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEBSTER GROVES ORTHODONTICS LTD

Provider Business Mailing Address
First Line	:	24 S GORE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2910
Country	:	US
Telephone Number	:	314-962-6242
Fax Number	:	314-962-3030

Provider Business Practice Location Address
First Line	:	24 S GORE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2910
Country	:	US
Telephone Number	:	314-962-6242
Fax Number	:	314-962-3030

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PETER M CRUMP
Credential	:
Telephone Number	:	314-962-6242

Provider Enumeration Date	:	03/04/2014
Last Update Date	:	03/04/2014

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