Provider Demographics
NPI:1568939593
Name:ST.LOUIS CENTER FOR AESTHETIC AND RESTOR. DENTISTRY/LINDBERGH SMILE
Entity Type:Organization
Organization Name:ST.LOUIS CENTER FOR AESTHETIC AND RESTOR. DENTISTRY/LINDBERGH SMILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPPORT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-753-8154
Mailing Address - Street 1:1422 ELBRIDGE PAYNE RD STE 240
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8544
Mailing Address - Country:US
Mailing Address - Phone:314-753-8154
Mailing Address - Fax:
Practice Address - Street 1:7934 N LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-3521
Practice Address - Country:US
Practice Address - Phone:314-831-8086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOH OF MISSOURI SAMSON LIU PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty