1336314079 NPI number — STEPHEN W. HIATT DDS AND MARYANN L. UDY DMD PC

Table of content: (NPI 1336314079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336314079 NPI number — STEPHEN W. HIATT DDS AND MARYANN L. UDY DMD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN W. HIATT DDS AND MARYANN L. UDY DMD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336314079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5551 WINGHAVEN BLVD. STE. 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O'FALLON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-978-6967
Provider Business Mailing Address Fax Number:
636-978-5905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2992 HIGHWAY K
Provider Second Line Business Practice Location Address:
STE 133
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63368-7861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-978-6967
Provider Business Practice Location Address Fax Number:
636-978-5905
Provider Enumeration Date:
04/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WISNIEWSKI
Authorized Official First Name:
LANA
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
636-978-6967

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  011813 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com