Healthcare Provider Details

I. General information

NPI: 1598510695
Provider Name (Legal Business Name): POORNIMA RANGANATHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2941 HIGHWAY K
O FALLON MO
63368-7862
US

IV. Provider business mailing address

160 TURION LN
WENTZVILLE MO
63385-6019
US

V. Phone/Fax

Practice location:
  • Phone: 636-388-4066
  • Fax:
Mailing address:
  • Phone: 314-255-8779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2026024967
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: