Healthcare Provider Details

I. General information

NPI: 1699281121
Provider Name (Legal Business Name): ST LOUIS SOUTH ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9911 KENNERLY RD STE H
SAINT LOUIS MO
63128-2700
US

IV. Provider business mailing address

9911 KENNERLY RD STE H
SAINT LOUIS MO
63128-2700
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-5583
  • Fax: 314-843-6495
Mailing address:
  • Phone: 314-843-5583
  • Fax: 314-843-6495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2013009439
License Number StateMO

VIII. Authorized Official

Name: DR. SENTHIL N ARUN
Title or Position: OWNER
Credential: DMD
Phone: 706-288-7538