Healthcare Provider Details

I. General information

NPI: 1811448863
Provider Name (Legal Business Name): WE CARE MOBILE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6903 WATERMAN AVE
SAINT LOUIS MO
63130-4333
US

IV. Provider business mailing address

6903 WATERMAN AVE
SAINT LOUIS MO
63130-4333
US

V. Phone/Fax

Practice location:
  • Phone: 314-276-8090
  • Fax:
Mailing address:
  • Phone: 314-276-8090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2011019745
License Number StateMO

VIII. Authorized Official

Name: MICHAEL TRAVIS
Title or Position: DENTIST
Credential: DDS
Phone: 314-452-1423