Provider Demographics
NPI:1417218249
Name:SOUTHWEST ENDODONTIC ASSOC.
Entity Type:Organization
Organization Name:SOUTHWEST ENDODONTIC ASSOC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:CYR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-781-1919
Mailing Address - Street 1:6651 CHIPPEWA
Mailing Address - Street 2:STE 323
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109
Mailing Address - Country:US
Mailing Address - Phone:314-781-1919
Mailing Address - Fax:314-781-0880
Practice Address - Street 1:6651 CHIPPEWA
Practice Address - Street 2:SUITE 323
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109
Practice Address - Country:US
Practice Address - Phone:314-781-1919
Practice Address - Fax:314-781-0880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST ENDODONTIC ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD140821223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty