Healthcare Provider Details

I. General information

NPI: 1598291486
Provider Name (Legal Business Name): BENTLEY JAMES ANDERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 16A
SAINT LOUIS MO
63141-8239
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 16A
SAINT LOUIS MO
63141-8239
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6725
  • Fax:
Mailing address:
  • Phone: 314-251-6725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2021011403
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2021011403
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: