Provider Demographics
NPI:1538140116
Name:STORM, BERNARD RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:RAY
Last Name:STORM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:B.
Other - Middle Name:RAY
Other - Last Name:STORM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:340 MID RIVERS MALL DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:ST PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1581
Mailing Address - Country:US
Mailing Address - Phone:636-279-1633
Mailing Address - Fax:636-397-8800
Practice Address - Street 1:340 MID RIVERS MALL DR
Practice Address - Street 2:SUITE E
Practice Address - City:ST PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1581
Practice Address - Country:US
Practice Address - Phone:636-279-1633
Practice Address - Fax:636-397-8800
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO128761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice