Provider Demographics
NPI:1538661087
Name:SOH OF MISSOURI
Entity Type:Organization
Organization Name:SOH OF MISSOURI
Other - Org Name:WELDON SPRING DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNSHINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-413-2803
Mailing Address - Street 1:810 OFALLON RD # I
Mailing Address - Street 2:
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-8102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 OFALLON RD # I
Practice Address - Street 2:
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-8102
Practice Address - Country:US
Practice Address - Phone:314-753-8154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOH OF MISSOURI SAMSON LIU PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-01
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000164557122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty