Provider Demographics
NPI:1568669349
Name:WYDOWN DENTAL GROUP, INC.
Entity type:Organization
Organization Name:WYDOWN DENTAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-721-2346
Mailing Address - Street 1:510 S HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2038
Mailing Address - Country:US
Mailing Address - Phone:314-721-2346
Mailing Address - Fax:
Practice Address - Street 1:510 S HANLEY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-2038
Practice Address - Country:US
Practice Address - Phone:314-721-2346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty