1487155925 NPI number — GATEWAY DENTAL GROUP SCHREINER DDS LLC

Table of content: JESSICA MARIE MILLER OTR (NPI 1881338440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487155925 NPI number — GATEWAY DENTAL GROUP SCHREINER DDS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATEWAY DENTAL GROUP SCHREINER DDS LLC
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:
1487155925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18009 TARA WOODS COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-721-5551
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7171 DELMAR BLVD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-721-5551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SCHREINER
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
314-518-1088

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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