Healthcare Provider Details

I. General information

NPI: 1720290372
Provider Name (Legal Business Name): DESHMUKH DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD SUITE #740
SAINT LOUIS MO
63117-1223
US

IV. Provider business mailing address

1034 S BRENTWOOD BLVD SUITE #740
SAINT LOUIS MO
63117-1223
US

V. Phone/Fax

Practice location:
  • Phone: 314-725-4221
  • Fax: 314-725-4319
Mailing address:
  • Phone: 314-725-4221
  • Fax: 314-725-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number015495
License Number StateMO

VIII. Authorized Official

Name: DR. VIDESH DAMODAR DESHMUKH
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 314-725-4221