MEDICARE: DR. SAMIR KHATTAB EL MOFTY DMD

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	1223P0106X	Oral and Maxillofacial Pathology Dentistry	014731	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558387878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMIR KHATTAB EL MOFTY DMD

Provider Business Mailing Address
First Line	:	4253 CLAYTON AVE
Second Line	:	CB 8118
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110
Country	:	US
Telephone Number	:	314-362-5641
Fax Number	:	314-362-0369

Provider Business Practice Location Address
First Line	:	425 S EUCLID AVE
Second Line	:	3RD FLOOR
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-1005
Country	:	US
Telephone Number	:	314-362-5641
Fax Number	:	314-362-0369

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

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	10/23/2015

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