Provider Demographics
NPI:1073800520
Name:MOREL-MAYNARD, DOMINIC (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:
Last Name:MOREL-MAYNARD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD STE 16A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8239
Mailing Address - Country:US
Mailing Address - Phone:314-251-6725
Mailing Address - Fax:314-251-6726
Practice Address - Street 1:621 S NEW BALLAS RD STE 16A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8239
Practice Address - Country:US
Practice Address - Phone:314-251-6725
Practice Address - Fax:314-251-6726
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180108761223S0112X
FLDN 217611223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty