Basic Information
| Provider Information | |||||||||
| NPI: | 1922480987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SERRANO | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4352 MANCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143710336 | ||||||||
| FaxNumber: | 3145310063 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 HOLLY HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631112410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146782971 | ||||||||
| FaxNumber: | 3143537631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2015020291 | MO | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 2015020291 | 01 | MO | DENTAL LICENSE | OTHER |