Provider Demographics
NPI:1134345093
Name:SOUTHSIDE DENTAL CARE, L.L.C.
Entity type:Organization
Organization Name:SOUTHSIDE DENTAL CARE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRI
Authorized Official - Middle Name:HUONG
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-865-3838
Mailing Address - Street 1:3654 GRAVOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4728
Mailing Address - Country:US
Mailing Address - Phone:314-865-3838
Mailing Address - Fax:314-865-2419
Practice Address - Street 1:3654 GRAVOIS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4728
Practice Address - Country:US
Practice Address - Phone:314-865-3838
Practice Address - Fax:314-865-2419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200-101-13471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty