Provider Demographics
NPI:1437146438
Name:KING, EUSTACE EUGENE IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:EUSTACE
Middle Name:EUGENE
Last Name:KING
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 HAZELWEST DR
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1748
Mailing Address - Country:US
Mailing Address - Phone:314-731-5464
Mailing Address - Fax:314-731-3128
Practice Address - Street 1:807 HAZELWEST DR
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1748
Practice Address - Country:US
Practice Address - Phone:314-731-5464
Practice Address - Fax:314-731-3128
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice