Provider Demographics
NPI:1891811790
Name:GATES, JODY GIARDINA (RDH)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:GIARDINA
Last Name:GATES
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 SUGAR GROVE COURT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4406
Mailing Address - Country:US
Mailing Address - Phone:314-469-2309
Mailing Address - Fax:
Practice Address - Street 1:111 SOUTH MERAMEC AVENUE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-1711
Practice Address - Country:US
Practice Address - Phone:314-615-5735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002683124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist