Provider Demographics
NPI:1245396134
Name:ST. CHARLES COUNTY ORTHODONCTICS WEST
Entity Type:Organization
Organization Name:ST. CHARLES COUNTY ORTHODONCTICS WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:V
Authorized Official - Last Name:MORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:636-332-5550
Mailing Address - Street 1:1139 WENTZVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3404
Mailing Address - Country:US
Mailing Address - Phone:636-332-5550
Mailing Address - Fax:636-332-4386
Practice Address - Street 1:1139 WENTZVILLE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3404
Practice Address - Country:US
Practice Address - Phone:636-332-5550
Practice Address - Fax:636-332-4386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO133331223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty