Midwest Mobile Dentistry LLC

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

Legal business name

MIDWEST MOBILE DENTISTRY LLC

Practice address

1 N Brentwood Blvd Ste 1000
Saint Louis, MO 63105-3937

Phone

(225) 287-8765

Fax

(615) 225-8915

NPI assigned

Jun 26, 2017

Last updated

Jul 21, 2022By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jeremy Gordon Graham, DDS

Title

Owner/Ceo

Phone

(225) 287-8765

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1498435200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1417477985",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 NORTH BRENTWOOD BOULEVARD",
            "address_2": "SUITE 1000",
            "city": "ST LOUIS",
            "state": "MO",
            "postal_code": "63105",
            "telephone_number": "225-287-8765",
            "fax_number": "615-225-8915"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 N BRENTWOOD BLVD STE 1000",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631053937",
            "telephone_number": "225-287-8765",
            "fax_number": "615-225-8915"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIDWEST MOBILE DENTISTRY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-06-26",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "GRAHAM",
        "authorized_official_first_name": "JEREMY",
        "authorized_official_middle_name": "GORDON",
        "authorized_official_title_or_position": "OWNER/CEO",
        "authorized_official_telephone_number": "225-287-8765",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "MO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dental Clinic/Center in Saint Louis, MO
• Providers in Saint Louis, MO by specialty
• Dental Clinic/Center in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.