Healthcare Provider Details

I. General information

NPI: 1568225779
Provider Name (Legal Business Name): ATOUSA CHOOPANI DASTGERDI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 S FRANKLIN ST STE A
CUBA MO
65453-1408
US

IV. Provider business mailing address

1081 E 18TH ST
ROLLA MO
65401-3398
US

V. Phone/Fax

Practice location:
  • Phone: 573-426-4455
  • Fax:
Mailing address:
  • Phone: 872-228-6672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2026023904
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: