Healthcare Provider Details

I. General information

NPI: 1689089500
Provider Name (Legal Business Name): BRIAN JUDD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 HAMPTON VILLAGE PLZ STE 225
SAINT LOUIS MO
63109-2109
US

IV. Provider business mailing address

16 HAMPTON VILLAGE PLZ STE 225
SAINT LOUIS MO
63109-2109
US

V. Phone/Fax

Practice location:
  • Phone: 314-916-5757
  • Fax: 314-916-5758
Mailing address:
  • Phone: 314-916-5757
  • Fax: 314-916-5758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2019024072
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: