Healthcare Provider Details

I. General information

NPI: 1447516794
Provider Name (Legal Business Name): BRADLEY ROSS CARN D.M.D., MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S WOODS MILL RD STE 720N
CHESTERFIELD MO
63017
US

IV. Provider business mailing address

222 S WOODS MILL RD STE 720N
CHESTERFIELD MO
63017-3650
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-0493
  • Fax: 314-434-7883
Mailing address:
  • Phone: 314-434-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2018008864
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD5998
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2018228864
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: