Provider Demographics
NPI:1457599664
Name:SENIOR CARE DENTISTRY
Entity Type:Organization
Organization Name:SENIOR CARE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O./PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEDNAM
Authorized Official - Suffix:SR
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-268-6135
Mailing Address - Street 1:3535 S JEFFERSON AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-3935
Mailing Address - Country:US
Mailing Address - Phone:314-268-6135
Mailing Address - Fax:314-268-6117
Practice Address - Street 1:3535 S JEFFERSON AVE STE 302
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3935
Practice Address - Country:US
Practice Address - Phone:314-268-6135
Practice Address - Fax:314-268-6117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty