Provider Demographics
NPI:1518158989
Name:GREATER ST LOUIS ORAL & MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:GREATER ST LOUIS ORAL & MAXILLOFACIAL SURGERY PC
Other - Org Name:MONTERUBIO AND HERBOSA ORAL AND MAXILLOFACIAL SURGERY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTERUBIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-721-1010
Mailing Address - Street 1:1034 S BRENTWOOD BLVD
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1223
Mailing Address - Country:US
Mailing Address - Phone:314-721-1010
Mailing Address - Fax:314-721-5276
Practice Address - Street 1:1034 S BRENTWOOD BLVD
Practice Address - Street 2:SUITE 1010
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1223
Practice Address - Country:US
Practice Address - Phone:314-721-1010
Practice Address - Fax:314-721-5276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty