=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952292005
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDE DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2025
-----------------------------------------------------
Last Update Date | 07/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14377 WOODLAKE DR STE 205
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-5735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-576-0088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2211 OLIVE ST STE 100
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63103-1502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-776-7100
-----------------------------------------------------
Fax | 314-776-7469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ GENERAL DENTIST
-----------------------------------------------------
Name | PHILIP SON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 323-787-9397
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------