Healthcare Provider Details

I. General information

NPI: 1053273482
Provider Name (Legal Business Name): MONTICELLO SLEEP DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 HUBER PARK CT STE 201
WELDON SPRING MO
63304-8621
US

IV. Provider business mailing address

530 HUBER PARK CT STE 201
WELDON SPRING MO
63304-8621
US

V. Phone/Fax

Practice location:
  • Phone: 636-244-2080
  • Fax:
Mailing address:
  • Phone: 636-244-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NUMPOL DEJTIRANUKUL
Title or Position: SOLE MBR/DENTIST
Credential: DMD
Phone: 636-299-7737