Healthcare Provider Details

I. General information

NPI: 1255759197
Provider Name (Legal Business Name): RYAN RADER ENTERPRISES DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11709 OLD BALLAS RD STE 206
CREVE COEUR MO
63141-7029
US

IV. Provider business mailing address

11709 OLD BALLAS RD STE 206
CREVE COEUR MO
63141-7029
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-3760
  • Fax: 314-567-3929
Mailing address:
  • Phone: 314-567-3760
  • Fax: 314-567-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2006016236
License Number StateMO

VIII. Authorized Official

Name: DR. RYAN LEE RADER
Title or Position: OWNER
Credential: D.M.D., M.S.
Phone: 314-567-3760