Provider Demographics
NPI:1740279967
Name:MARISCAL, ERIN (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIN
Middle Name:
Last Name:MARISCAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 RICHARDSON XING
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-6023
Mailing Address - Country:US
Mailing Address - Phone:636-464-6444
Mailing Address - Fax:636-464-6465
Practice Address - Street 1:124 RICHARDSON XING
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-6023
Practice Address - Country:US
Practice Address - Phone:636-464-6444
Practice Address - Fax:636-464-6465
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003013103122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO405384108Medicaid