Healthcare Provider Details

I. General information

NPI: 1225274681
Provider Name (Legal Business Name): BRIDGEPORT DENTAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2009
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 WESTBURY DR SUITE D
SAINT CHARLES MO
63301-2543
US

IV. Provider business mailing address

12 WESTBURY DR SUITE D
SAINT CHARLES MO
63301-2543
US

V. Phone/Fax

Practice location:
  • Phone: 636-925-2787
  • Fax: 636-925-2829
Mailing address:
  • Phone: 636-925-2787
  • Fax: 636-925-2829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number010435
License Number StateMO

VIII. Authorized Official

Name: KRISTINE USRY
Title or Position: MANAGER OF FINANCE
Credential:
Phone: 636-925-2787