Healthcare Provider Details

I. General information

NPI: 1326123647
Provider Name (Legal Business Name): SUNSET HILLS DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11810 GRAVOIS RD
ST LOUIS MO
63127
US

IV. Provider business mailing address

PO BOX 8570
ST LOUIS MO
63126-0570
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-5000
  • Fax: 314-842-7199
Mailing address:
  • Phone: 314-842-5000
  • Fax: 314-842-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: PHYLLIS M AHRENS
Title or Position: INSURANCE DEPT REP
Credential:
Phone: 3148425000827