Provider Demographics
NPI:1912056151
Name:KLEITZ DMD RICHARDSON DMD PC
Entity Type:Organization
Organization Name:KLEITZ DMD RICHARDSON DMD PC
Other - Org Name:DES PERES DENTAL GROUP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-822-3868
Mailing Address - Street 1:13603 BARRETT OFFICE DRIVE
Mailing Address - Street 2:STE 104
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7828
Mailing Address - Country:US
Mailing Address - Phone:314-822-3868
Mailing Address - Fax:314-822-1101
Practice Address - Street 1:13603 BARRETT OFFICE DRIVE
Practice Address - Street 2:STE 104
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63021-7828
Practice Address - Country:US
Practice Address - Phone:314-822-3868
Practice Address - Fax:314-822-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO122341223G0001X
MO122221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty