Healthcare Provider Details

I. General information

NPI: 1780989061
Provider Name (Legal Business Name): PEDAITRIC DENTAL AND ORTHODONTIC ASSOCIATES OF ST LOUIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 S CLAY AVE
KIRKWOOD MO
63122-5808
US

IV. Provider business mailing address

430 S CLAY AVE
KIRKWOOD MO
63122-5808
US

V. Phone/Fax

Practice location:
  • Phone: 314-965-7630
  • Fax:
Mailing address:
  • Phone: 314-965-7630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14227
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14227
License Number StateMO

VIII. Authorized Official

Name: DR. THOMAS VERALDI
Title or Position: OWNER
Credential: D.M.D.
Phone: 314-965-7630