Healthcare Provider Details

I. General information

NPI: 1184816431
Provider Name (Legal Business Name): PEARLINE, DDS & ROACH, DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 S NEW BALLAS RD STE 201W
SAINT LOUIS MO
63141-8717
US

IV. Provider business mailing address

777 S NEW BALLAS RD STE 201W
SAINT LOUIS MO
63141-8717
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-5859
  • Fax: 314-991-1896
Mailing address:
  • Phone: 314-991-5859
  • Fax: 314-991-1896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number012927
License Number StateMO

VIII. Authorized Official

Name: DR. RODRICK EVAN PEARLINE
Title or Position: PRESIDENT
Credential: DDS
Phone: 314-991-5850