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General NPI Number Information
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NPI Number | 1871479758
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Entity Type | Organization
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Legal Business Name | PLD OF SOUTH CITY PC
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Dates
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Enumeration Date | 08/14/2025
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Last Update Date | 08/14/2025
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Provider Practice Location Address
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Address Line | 3859 GRAVOIS AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63116-4657
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Country | US
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Telephone | 314-382-2000
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Fax | 314-382-2411
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Provider Business Mailing Address
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Address Line | 3708 JENNINGS STATION RD
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City | SAINT LOUIS
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State | MO
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Zip | 63121-3500
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Country | US
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Telephone | 314-382-2000
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Fax | 314-382-2411
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHAEL TRAVIS
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Credential | DDS
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Telephone | 314-635-0822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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