MEDICARE: DR. BENTLEY JAMES ANDERSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2021011403	MO
2	390200000X	Student in an Organized Health Care Education/Training Program
3	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	2021011403	MO

General Provider Information

NPI Number	:	1598291486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENTLEY JAMES ANDERSON DDS

Provider Business Mailing Address
First Line	:	621 S NEW BALLAS RD STE 16A
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8239
Country	:	US
Telephone Number	:	314-251-6725
Fax Number	:

Provider Business Practice Location Address
First Line	:	621 S NEW BALLAS RD STE 16A
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8239
Country	:	US
Telephone Number	:	314-251-6725
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	07/07/2021

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