Provider Demographics
NPI:1912471921
Name:WILLIAM J. PAVLISIN, D.D.S., P.C.
Entity type:Organization
Organization Name:WILLIAM J. PAVLISIN, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PAVLISIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-481-5150
Mailing Address - Street 1:9021 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-4625
Mailing Address - Country:US
Mailing Address - Phone:314-481-5150
Mailing Address - Fax:314-481-5150
Practice Address - Street 1:9021 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-4625
Practice Address - Country:US
Practice Address - Phone:314-481-5150
Practice Address - Fax:314-481-5150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
13525144OtherCAQH