Healthcare Provider Details

I. General information

NPI: 1992297824
Provider Name (Legal Business Name): BRADLEY STANLEY LONDON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3721 JENNINGS STATION RD
SAINT LOUIS MO
63121-3505
US

IV. Provider business mailing address

3721 JENNINGS STATION RD
SAINT LOUIS MO
63121-3505
US

V. Phone/Fax

Practice location:
  • Phone: 314-382-2000
  • Fax:
Mailing address:
  • Phone: 314-382-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2018017829
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2018017829
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: