Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 15707 | MO |
NPI | 1073541629 |
---|---|
Provider Name | Dr. Roy Dennis Bedrock |
First Address | Clayton, MO 63105-2465 |
Second Address | Clayton, MO 63105-2465 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2006 |
Last Update Date | 08/07/2007 |