Provider Demographics
NPI:1720650013
Name:MAYFIELD, DEVERICK M (DMD)
Entity Type:Individual
Prefix:
First Name:DEVERICK
Middle Name:M
Last Name:MAYFIELD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2646
Mailing Address - Country:US
Mailing Address - Phone:217-821-0445
Mailing Address - Fax:
Practice Address - Street 1:3750 S LINDBERGH BLVD STE 102
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1375
Practice Address - Country:US
Practice Address - Phone:217-821-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210259181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice