Provider Demographics
NPI:1811180540
Name:BRENTWOOD FAMILY DENTAL CENTER, LLC
Entity type:Organization
Organization Name:BRENTWOOD FAMILY DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIGLESS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-647-1100
Mailing Address - Street 1:8083 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2817
Mailing Address - Country:US
Mailing Address - Phone:314-647-1100
Mailing Address - Fax:314-647-1120
Practice Address - Street 1:8083 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2817
Practice Address - Country:US
Practice Address - Phone:314-647-1100
Practice Address - Fax:314-647-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0161291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty