Healthcare Provider Details

I. General information

NPI: 1699439125
Provider Name (Legal Business Name): SAINT JOHN DENTAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2021
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8938 SAINT CHARLES ROCK RD
SAINT LOUIS MO
63114-4238
US

IV. Provider business mailing address

15255 NOONING TREE CT # NA
CHESTERFIELD MO
63017-4401
US

V. Phone/Fax

Practice location:
  • Phone: 314-225-4256
  • Fax:
Mailing address:
  • Phone: 314-225-4256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SCOTT RUBIS
Title or Position: DENTIST
Credential:
Phone: 314-225-4256