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General NPI Number Information
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NPI Number | 1417477985
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Entity Type | Organization
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Legal Business Name | MIDWEST MOBILE DENTISTRY LLC
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Dates
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Enumeration Date | 06/26/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1 N BRENTWOOD BLVD STE 1000
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City | SAINT LOUIS
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State | MO
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Zip | 63105-3937
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Country | US
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Telephone | 225-287-8765
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Fax | 615-225-8915
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Provider Business Mailing Address
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Address Line | 1 NORTH BRENTWOOD BOULEVARD SUITE 1000
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City | ST LOUIS
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State | MO
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Zip | 63105
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Country | US
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Telephone | 225-287-8765
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Fax | 615-225-8915
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Authorized Official
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Title or Position | OWNER/CEO
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Name | JEREMY GORDON GRAHAM
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Credential | DDS
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Telephone | 225-287-8765
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State | MO
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