MEDICARE: DR. MARYANA F KIROLOS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019028806	IL

General Provider Information

NPI Number	:	1114205929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARYANA F KIROLOS D.D.S.

Provider Business Mailing Address
First Line	:	26 KENTOM DR
Second Line	:
City	:	OLIVETTE
State	:	MO
Zip	:	63132-4108
Country	:	US
Telephone Number	:	314-442-6446
Fax Number	:	314-442-6446

Provider Business Practice Location Address
First Line	:	2608 STATE ST
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62205-2325
Country	:	US
Telephone Number	:	618-857-2300
Fax Number	:	618-857-2302

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2011
Last Update Date	:	07/27/2011

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