Provider Demographics
NPI:1922394790
Name:STORR, JILLIAN NOELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:NOELLE
Last Name:STORR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2172 ORCHID BLOSSOM CT
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7811
Mailing Address - Country:US
Mailing Address - Phone:636-345-9245
Mailing Address - Fax:
Practice Address - Street 1:2048 1ST CAPITOL DRIVE
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-1647
Practice Address - Country:US
Practice Address - Phone:636-345-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012032807122300000X
TN93251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice