Provider Demographics
NPI:1891987954
Name:WASHINGTON SQUARE DENTAL
Entity Type:Organization
Organization Name:WASHINGTON SQUARE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC
Authorized Official - Phone:636-239-7828
Mailing Address - Street 1:1015 WASHINGTON SQ STE E
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-5307
Mailing Address - Country:US
Mailing Address - Phone:636-239-7828
Mailing Address - Fax:636-239-5048
Practice Address - Street 1:1015 WASHINGTON SQ STE E
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-5307
Practice Address - Country:US
Practice Address - Phone:636-239-7828
Practice Address - Fax:636-239-5048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040132541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty