Healthcare Provider Details

I. General information

NPI: 1720144678
Provider Name (Legal Business Name): MARC BRUCE ABRAMS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 N NEW BALLAS RD SUITE 249
CREVE COEUR MO
63141-6831
US

IV. Provider business mailing address

456 N NEW BALLAS RD SUITE 249
CREVE COEUR MO
63141-6831
US

V. Phone/Fax

Practice location:
  • Phone: 314-569-2201
  • Fax: 314-569-2320
Mailing address:
  • Phone: 314-569-2201
  • Fax: 314-569-2320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11777
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: