Provider Demographics
NPI:1962618447
Name:ST.PETERS, EDWARD LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEE
Last Name:ST.PETERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 BERKSHIRE BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-1326
Mailing Address - Country:US
Mailing Address - Phone:618-259-7952
Mailing Address - Fax:
Practice Address - Street 1:707 BERKSHIRE BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-1326
Practice Address - Country:US
Practice Address - Phone:618-259-7952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice