Healthcare Provider Details

I. General information

NPI: 1730544818
Provider Name (Legal Business Name): E. BROWN, DDS, C. HOLLANDER, DDS, M. FERNANDEZ, DDS, D. AUTRY, DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 SUNSET OFFICE DR STE 210
SAINT LOUIS MO
63127-1021
US

IV. Provider business mailing address

3555 SUNSET OFFICE DR STE 210
SAINT LOUIS MO
63127-1021
US

V. Phone/Fax

Practice location:
  • Phone: 314-822-2764
  • Fax:
Mailing address:
  • Phone: 314-822-2764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number015561
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2004013229
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2005019770
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2013016355
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2014017371
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number015079
License Number StateMO

VIII. Authorized Official

Name: DR. DANIEL AUTRY
Title or Position: OWNER
Credential: DMD
Phone: 314-822-2764