Active NPI
Mark Eidelman, DDS
- General Practice Dentistry
- Saint Peters, MO
National Provider Identifier
1154468858
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 11785
- Practice address
- 300 Mid Rivers Mall Dr
Saint Peters, MO 63376-1565 - Phone
- (636) 397-5883
- Fax
- (636) 397-5887
- NPI assigned
- Jan 31, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 11785 | MO | Primary |
Addresses
Primary practice location
300 Mid Rivers Mall Dr
Saint Peters, MO 63376-1565
Mailing address
300 Mid Rivers Mall Dr
Saint Peters, MO 63376-1565
Phone (636) 397-5883
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11785 | MO | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1170201600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1154468858",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "300 MID RIVERS MALL DR",
"city": "SAINT PETERS",
"state": "MO",
"postal_code": "633761565",
"telephone_number": "636-397-5883",
"fax_number": "636-397-5887"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "300 MID RIVERS MALL DR",
"city": "SAINT PETERS",
"state": "MO",
"postal_code": "633761565",
"telephone_number": "636-397-5883",
"fax_number": "636-397-5887"
}
],
"practiceLocations": [],
"basic": {
"last_name": "EIDELMAN",
"first_name": "MARK",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-01-31",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "MO",
"license": "11785",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Saint Peters, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.