Provider Demographics
NPI:1043692858
Name:DAMICO, JULIE EDINGTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:EDINGTON
Last Name:DAMICO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JULIE
Other - Middle Name:EDINGTON DAMICO
Other - Last Name:FARRAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:11166 TESSON FERRY RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6966
Mailing Address - Country:US
Mailing Address - Phone:314-842-6666
Mailing Address - Fax:
Practice Address - Street 1:11166 TESSON FERRY RD
Practice Address - Street 2:SUITE 210
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6966
Practice Address - Country:US
Practice Address - Phone:314-842-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015020784122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist