Healthcare Provider Details

I. General information

NPI: 1871479758
Provider Name (Legal Business Name): PLD OF SOUTH CITY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2025
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3859 GRAVOIS AVE
SAINT LOUIS MO
63116-4657
US

IV. Provider business mailing address

3708 JENNINGS STATION RD
SAINT LOUIS MO
63121-3500
US

V. Phone/Fax

Practice location:
  • Phone: 314-382-2000
  • Fax: 314-382-2411
Mailing address:
  • Phone: 314-382-2000
  • Fax: 314-382-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL TRAVIS
Title or Position: OWNER
Credential: DDS
Phone: 314-635-0822