Healthcare Provider Details

I. General information

NPI: 1235071317
Provider Name (Legal Business Name): STL DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3654 GRAVOIS AVE
SAINT LOUIS MO
63116-4728
US

IV. Provider business mailing address

3654 GRAVOIS AVE
SAINT LOUIS MO
63116-4728
US

V. Phone/Fax

Practice location:
  • Phone: 314-865-3838
  • Fax: 314-865-2419
Mailing address:
  • Phone: 314-865-3838
  • Fax: 314-865-2419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRI LY
Title or Position: DENTIST
Credential:
Phone: 314-865-3838