Provider Demographics
NPI:1346394970
Name:GATEWAY ORAL HEALTH FOUNDATION
Entity Type:Organization
Organization Name:GATEWAY ORAL HEALTH FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:V
Authorized Official - Last Name:DEVALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-872-3930
Mailing Address - Street 1:9378 OLIVE ST STE ILL
Mailing Address - Street 2:
Mailing Address - City:OLIVETTE
Mailing Address - State:MO
Mailing Address - Zip Code:63132-9378
Mailing Address - Country:US
Mailing Address - Phone:314-872-3930
Mailing Address - Fax:314-872-3952
Practice Address - Street 1:9378 OLIVE ST STE ILL
Practice Address - Street 2:GATEWAY ORAL HEALTH FOUNDATION
Practice Address - City:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132-9378
Practice Address - Country:US
Practice Address - Phone:314-872-3930
Practice Address - Fax:314-872-3952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOM00134191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty