Healthcare Provider Details

I. General information

NPI: 1821944240
Provider Name (Legal Business Name): POUREDOUT DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10777 SUNSET OFFICE DR
SAINT LOUIS MO
63127-1052
US

IV. Provider business mailing address

10777 SUNSET OFFICE DR
SAINT LOUIS MO
63127-1052
US

V. Phone/Fax

Practice location:
  • Phone: 573-261-4399
  • Fax:
Mailing address:
  • Phone: 573-261-4399
  • Fax:

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: TIMBERLEE MINOR
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-205-2230