Healthcare Provider Details

I. General information

NPI: 1467876086
Provider Name (Legal Business Name): STEPHEN LOUIS GROSS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7421 MEXICO RD SUITE 202
SAINT PETERS MO
63376-1369
US

IV. Provider business mailing address

7421 MEXICO RD SUITE 202
SAINT PETERS MO
63376-1369
US

V. Phone/Fax

Practice location:
  • Phone: 636-970-7902
  • Fax: 636-970-3359
Mailing address:
  • Phone: 636-970-7902
  • Fax: 636-970-3359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2011003086
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1742
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: