Healthcare Provider Details

I. General information

NPI: 1972137479
Provider Name (Legal Business Name): NICHOLAS BRANHAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ STE 230
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

1034 S BRENTWOOD BLVD STE 1010
SAINT LOUIS MO
63117-1210
US

V. Phone/Fax

Practice location:
  • Phone: 314-361-6006
  • Fax:
Mailing address:
  • Phone: 314-721-1010
  • Fax: 314-721-5276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2024009328
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: