Healthcare Provider Details

I. General information

NPI: 1053647008
Provider Name (Legal Business Name): SOUTH COUNTY DENTAL IMAGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12818 TESSON FERRY RD SUITE 204
SAINT LOUIS MO
63128-2945
US

IV. Provider business mailing address

1034 S BRENTWOOD BLVD SUITE 1010
SAINT LOUIS MO
63117-1223
US

V. Phone/Fax

Practice location:
  • Phone: 314-722-2033
  • Fax: 314-842-1590
Mailing address:
  • Phone: 314-721-1010
  • Fax: 314-721-5276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN R MONTERUBIO SR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 314-721-1010