Provider Demographics
NPI:1104066604
Name:FIRST, LOUISE R
Entity type:Individual
Prefix:DR
First Name:LOUISE
Middle Name:R
Last Name:FIRST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W PORT PLZ STE 205
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3121
Mailing Address - Country:US
Mailing Address - Phone:314-837-2120
Mailing Address - Fax:314-838-8400
Practice Address - Street 1:77 WESTPORT PLAZA DRIVE
Practice Address - Street 2:SUITE 205
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146
Practice Address - Country:US
Practice Address - Phone:314-837-2120
Practice Address - Fax:314-838-8400
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1174619514OtherBILLING NPI PRIVATE PRACTICE