Provider Demographics
NPI:1750573572
Name:KALISH, FRED MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:MICHAEL
Last Name:KALISH
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 1:16216 BAXTER RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4770
Mailing Address - Country:US
Mailing Address - Phone:636-532-2228
Mailing Address - Fax:
Practice Address - Street 1:16216 BAXTER RD
Practice Address - Street 2:SUITE 320
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4770
Practice Address - Country:US
Practice Address - Phone:636-532-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0122211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice