=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932474665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BALASUDHA BALADHANDAYUTHAM BDS, MSD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2012
-----------------------------------------------------
Last Update Date | 10/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 PARK AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63104-3024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-626-2878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3534 GRATIOT ST APT 612
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63103-2957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-422-0265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401418600
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | IA-0008154045
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------