Provider Demographics
NPI:1629366760
Name:ST. LOUIS PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:ST. LOUIS PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/OWNER OF PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:636-205-4639
Mailing Address - Street 1:4142 KEATON CROSSING BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8404
Mailing Address - Country:US
Mailing Address - Phone:636-205-4639
Mailing Address - Fax:314-594-0742
Practice Address - Street 1:4142 KEATON CROSSING BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8404
Practice Address - Country:US
Practice Address - Phone:636-205-4639
Practice Address - Fax:314-594-0742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100062811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty