Provider Demographics
NPI:1104377431
Name:SAINT LOUIS UNIVERSITY
Entity Type:Organization
Organization Name:SAINT LOUIS UNIVERSITY
Other - Org Name:CARDINAL GLENNON PEDIATRIC DENTAL SPECIALTIES AT SAINT LOUIS UNIV
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR-PEDIATRIC DENTISTR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:STOECKEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-977-8517
Mailing Address - Street 1:3320 RUTGER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1122
Mailing Address - Country:US
Mailing Address - Phone:314-977-7336
Mailing Address - Fax:314-977-8617
Practice Address - Street 1:3320 RUTGER ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1122
Practice Address - Country:US
Practice Address - Phone:314-977-7336
Practice Address - Fax:314-977-8617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000174326261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental