Provider Demographics
NPI:1417477985
Name:MIDWEST MOBILE DENTISTRY LLC
Entity Type:Organization
Organization Name:MIDWEST MOBILE DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-287-8765
Mailing Address - Street 1:1 NORTH BRENTWOOD BOULEVARD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105
Mailing Address - Country:US
Mailing Address - Phone:225-287-8765
Mailing Address - Fax:615-225-8915
Practice Address - Street 1:1 N BRENTWOOD BLVD STE 1000
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3937
Practice Address - Country:US
Practice Address - Phone:225-287-8765
Practice Address - Fax:615-225-8915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental