Provider Demographics
NPI:1972039501
Name:MYSTLDENTIST LLC
Entity Type:Organization
Organization Name:MYSTLDENTIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMEBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:UTHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-842-0440
Mailing Address - Street 1:4590 S LINDBERGH BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1832
Mailing Address - Country:US
Mailing Address - Phone:314-842-0440
Mailing Address - Fax:314-848-5847
Practice Address - Street 1:4590 S LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1832
Practice Address - Country:US
Practice Address - Phone:314-842-0440
Practice Address - Fax:314-849-5847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013578261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental