Healthcare Provider Details

I. General information

NPI: 1528742384
Provider Name (Legal Business Name): MR. SIMON TADROS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 09/25/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PARK AVE
SAINT LOUIS MO
63104-3024
US

IV. Provider business mailing address

9256 STAR CT
FRANKFORT IL
60423-9122
US

V. Phone/Fax

Practice location:
  • Phone: 314-833-2700
  • Fax:
Mailing address:
  • Phone: 708-307-4908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12014497A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: