Provider Demographics
NPI:1124990601
Name:PROVIDE DENTAL
Entity type:Organization
Organization Name:PROVIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:SON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:323-787-9397
Mailing Address - Street 1:13371 OLIVE BLVD # 3108
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3108
Mailing Address - Country:US
Mailing Address - Phone:314-878-5544
Mailing Address - Fax:
Practice Address - Street 1:13371 OLIVE BLVD # 3108
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3108
Practice Address - Country:US
Practice Address - Phone:314-878-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDE DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental