MEDICARE: GOLNESA ROUIE MIAB

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	2021028071	MO
2	122300000X	Dentist	019033266	IL

General Provider Information

NPI Number	:	1649840042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GOLNESA ROUIE MIAB

Provider Business Mailing Address
First Line	:	112 OLD OAKS DR
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63011-2705
Country	:	US
Telephone Number	:	314-498-8093
Fax Number	:

Provider Business Practice Location Address
First Line	:	2048 1ST CAPITOL DR
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-1647
Country	:	US
Telephone Number	:	314-498-8093
Fax Number	:

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

Provider Enumeration Date	:	06/28/2021
Last Update Date	:	11/07/2021

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Directions to “ GOLNESA ROUIE MIAB ” Practice Location

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