Provider Demographics
NPI:1871479758
Name:PLD OF SOUTH CITY PC
Entity type:Organization
Organization Name:PLD OF SOUTH CITY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-635-0822
Mailing Address - Street 1:3708 JENNINGS STATION RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-3500
Mailing Address - Country:US
Mailing Address - Phone:314-382-2000
Mailing Address - Fax:314-382-2411
Practice Address - Street 1:3859 GRAVOIS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4657
Practice Address - Country:US
Practice Address - Phone:314-382-2000
Practice Address - Fax:314-382-2411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty