Healthcare Provider Details

I. General information

NPI: 1215547997
Provider Name (Legal Business Name): SLEEP DENTISTRY -ST. LOUIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 FRANCIS PL STE 305
SAINT LOUIS MO
63105-2465
US

IV. Provider business mailing address

950 FRANCIS PL STE 305
SAINT LOUIS MO
63105-2465
US

V. Phone/Fax

Practice location:
  • Phone: 314-862-7844
  • Fax: 314-862-4504
Mailing address:
  • Phone: 314-862-7844
  • Fax: 314-862-4504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State

VIII. Authorized Official

Name: MARY LEA BOMMARITO
Title or Position: OFFICE MANAGER
Credential: OM
Phone: 314-862-7844