Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 2018010876 | MO |
N | 1223S0112X | Oral and Maxillofacial Surgeon | DN 21761 | FL |
NPI | 1073800520 |
---|---|
Provider Name | Dr. Dominic Morel-Maynard |
First Address | Saint Louis, MO 63141-8239 |
Second Address | Saint Louis, MO 63141-8239 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2011 |
Last Update Date | 18/01/2019 |