Provider Demographics
NPI:1073073227
Name:ST CLAIR FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ST CLAIR FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-566-9072
Mailing Address - Street 1:1008 TAMARISK DR
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5594
Mailing Address - Country:US
Mailing Address - Phone:314-566-9072
Mailing Address - Fax:
Practice Address - Street 1:525 E SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-1735
Practice Address - Country:US
Practice Address - Phone:636-629-1103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental