Provider Demographics
NPI:1053647008
Name:SOUTH COUNTY DENTAL IMAGING CENTER
Entity Type:Organization
Organization Name:SOUTH COUNTY DENTAL IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTERUBIO
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-721-1010
Mailing Address - Street 1:1034 S BRENTWOOD BLVD
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1223
Mailing Address - Country:US
Mailing Address - Phone:314-721-1010
Mailing Address - Fax:314-721-5276
Practice Address - Street 1:12818 TESSON FERRY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2945
Practice Address - Country:US
Practice Address - Phone:314-722-2033
Practice Address - Fax:314-842-1590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology