Provider Demographics
NPI:1972963460
Name:NEW CREATION CENTER FOR DENTAL SLEEP MEDICINE LLC
Entity type:Organization
Organization Name:NEW CREATION CENTER FOR DENTAL SLEEP MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-625-1225
Mailing Address - Street 1:15 LAKESIDE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1378
Mailing Address - Country:US
Mailing Address - Phone:636-625-1225
Mailing Address - Fax:636-625-1228
Practice Address - Street 1:15 LAKESIDE DR STE A
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1378
Practice Address - Country:US
Practice Address - Phone:636-625-1225
Practice Address - Fax:636-625-1228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030131061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7526580001Medicare NSC