Provider Demographics
NPI:1043479215
Name:NUMPOL DEJTIRANUKUL DMD LLC
Entity Type:Organization
Organization Name:NUMPOL DEJTIRANUKUL DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NUMPOL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJTIRANUKUL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-300-4280
Mailing Address - Street 1:4122 KEATON CROSSING BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8218
Mailing Address - Country:US
Mailing Address - Phone:636-300-4280
Mailing Address - Fax:
Practice Address - Street 1:4122 KEATON CROSSING BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8218
Practice Address - Country:US
Practice Address - Phone:636-300-4280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001702431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty