Provider Demographics
NPI:1154576890
Name:MCLEOD PERIODONTICS
Entity type:Organization
Organization Name:MCLEOD PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-731-1700
Mailing Address - Street 1:5992 HOWDERSHELL RD.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:HAZELWOOD
Mailing Address - State:MISSOURI
Mailing Address - Zip Code:63042
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5992 HOWDERSHELL RD
Practice Address - Street 2:SUITE 204
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-4107
Practice Address - Country:US
Practice Address - Phone:314-731-1700
Practice Address - Fax:314-731-1784
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD PERIODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0157871223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty