# MIDWEST MOBILE DENTISTRY LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1417477985
- **Authorized official:** JEREMY GORDON GRAHAM DDS (OWNER/CEO)
- **Authorized official phone:** (225) 287-8765

## Contact information

- **Practice address:** 1 N BRENTWOOD BLVD STE 1000, SAINT LOUIS, MO 63105-3937
- **Practice address phone:** (225) 287-8765
- **Practice address fax:** (615) 225-8915
- **Mailing address:** 1 NORTH BRENTWOOD BOULEVARD, SUITE 1000, ST LOUIS, MO 63105
- **Mailing address phone:** (225) 287-8765
- **Mailing address fax:** (615) 225-8915

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | — | MO | Yes |

## Other

- **Enumeration date:** 06/26/2017
- **Last updated:** 07/21/2022