Provider Demographics
NPI:1699776153
Name:PEARSON, WILLIAM KEITH (DDS)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:KEITH
Last Name:PEARSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 N KINGSHIGHWAY BLVD APT 4L
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1350
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-6326
Practice Address - Street 1:40 N KINGSHIGHWAY BLVD APT 4L
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1350
Practice Address - Country:US
Practice Address - Phone:314-367-5820
Practice Address - Fax:314-367-6326
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014703122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO402458855Medicaid
MO23484Medicare ID - Type Unspecified
MO402458855Medicaid
MO402458848Medicaid