Healthcare Provider Details

I. General information

NPI: 1770426215
Provider Name (Legal Business Name): ST LOUIS CHILDRENS GENERAL ANESTHESIA DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12101 WOODCREST EXECUTIVE DR STE 101
SAINT LOUIS MO
63141-5047
US

IV. Provider business mailing address

12101 WOODCREST EXECUTIVE DR STE 101
SAINT LOUIS MO
63141-5047
US

V. Phone/Fax

Practice location:
  • Phone: 301-494-3000
  • Fax:
Mailing address:
  • Phone: 301-494-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JEN ANTLE
Title or Position: EXEC ASST
Credential:
Phone: 541-219-2904