Provider Demographics
NPI:1164650883
Name:UDY, MARYANN L (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:L
Last Name:UDY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5551 WINGHAVEN BLVD., STE 210
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368
Mailing Address - Country:US
Mailing Address - Phone:636-978-6967
Mailing Address - Fax:636-978-5905
Practice Address - Street 1:5551 WINGHAVEN BLVD., STE 210
Practice Address - Street 2:
Practice Address - City:O'FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368
Practice Address - Country:US
Practice Address - Phone:636-978-6967
Practice Address - Fax:636-978-5905
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20130097711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery