Healthcare Provider Details

I. General information

NPI: 1649661513
Provider Name (Legal Business Name): ROLF GORDON BEHRENTS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

IV. Provider business mailing address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8602
  • Fax:
Mailing address:
  • Phone: 314-977-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2011041074
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: