Provider Demographics
NPI:1558409177
Name:RONECKER, JEFFERY ALAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:ALAN
Last Name:RONECKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6457 S KINGSHIGHWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-3782
Mailing Address - Country:US
Mailing Address - Phone:314-352-3883
Mailing Address - Fax:314-352-7663
Practice Address - Street 1:6457 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-3782
Practice Address - Country:US
Practice Address - Phone:314-352-3883
Practice Address - Fax:314-352-7663
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14305122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist