Provider Demographics
NPI:1275603557
Name:CENTENO, JANE (DMD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:CENTENO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 N. EUCLID SUITE 220
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108
Mailing Address - Country:US
Mailing Address - Phone:314-367-7702
Mailing Address - Fax:
Practice Address - Street 1:22 N. EUCLID SUITE 220
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108
Practice Address - Country:US
Practice Address - Phone:314-367-7702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO46173541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice