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General NPI Number Information
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NPI Number | 1114012200
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Entity Type | Individual
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Provider Name | FREIDA CAROLE GRIMES-MOORE DDS
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Gender | Female
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 06/20/2025
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Provider Practice Location Address
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Address Line | 614 S FLORISSANT RD
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City | SAINT LOUIS
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State | MO
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Zip | 63135-2948
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Country | US
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Telephone | 901-864-1990
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Fax |
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Provider Business Mailing Address
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Address Line | 614 S FLORISSANT RD
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City | SAINT LOUIS
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State | MO
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Zip | 63135-2948
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Country | US
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Telephone | 901-864-1990
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS3040
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2018001854
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License Number State | MO
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