Healthcare Provider Details

I. General information

NPI: 1174288153
Provider Name (Legal Business Name): RAVEN ELAINE YAYAH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4905 STONE FALLS CTR UNIT A
O FALLON IL
62269-7802
US

IV. Provider business mailing address

4201 W PINE BLVD APT 103
SAINT LOUIS MO
63108-3078
US

V. Phone/Fax

Practice location:
  • Phone: 618-622-3377
  • Fax:
Mailing address:
  • Phone: 901-849-9389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2021044569
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019.034684
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: