Provider Demographics
NPI:1336314079
Name:STEPHEN W. HIATT DDS AND MARYANN L. UDY DMD PC
Entity Type:Organization
Organization Name:STEPHEN W. HIATT DDS AND MARYANN L. UDY DMD PC
Other - Org Name:GEORGE T. SHUERT DDS AND STEPHEN W. HIATT DDS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WISNIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-978-6967
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 1:2992 HIGHWAY K
Practice Address - Street 2:STE 133
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7861
Practice Address - Country:US
Practice Address - Phone:636-978-6967
Practice Address - Fax:636-978-5905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0118131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990001251Medicare PIN