Healthcare Provider Details

I. General information

NPI: 1366414575
Provider Name (Legal Business Name): RICHARD LANE O'BRIEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 HAMPTON AVE
SAINT LOUIS MO
63109-2749
US

IV. Provider business mailing address

4607 HAMPTON AVE
SAINT LOUIS MO
63109-2749
US

V. Phone/Fax

Practice location:
  • Phone: 314-481-3369
  • Fax: 314-481-5386
Mailing address:
  • Phone: 314-481-3369
  • Fax: 314-481-5386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number011055
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number011055
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: