Healthcare Provider Details

I. General information

NPI: 1053574517
Provider Name (Legal Business Name): GIOVANNI A SAFDARI MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2008
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 NEBRASKA AVE USA DENTAC
FT LEONARD WOOD MO
65473
US

IV. Provider business mailing address

1724 NEBRASKA AVE USA DENTAC
FT LEONARD WOOD MO
65473
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0388
  • Fax: 573-596-0410
Mailing address:
  • Phone: 573-596-0388
  • Fax: 573-596-0410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2008019427
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2008019427
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: