Healthcare Provider Details

I. General information

NPI: 1649840042
Provider Name (Legal Business Name): GOLNESA ROUIE MIAB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 11/07/2021
Certification Date: 11/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2048 1ST CAPITOL DR
SAINT CHARLES MO
63301-1647
US

IV. Provider business mailing address

112 OLD OAKS DR
BALLWIN MO
63011-2705
US

V. Phone/Fax

Practice location:
  • Phone: 314-498-8093
  • Fax:
Mailing address:
  • Phone: 314-498-8093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019033266
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2021028071
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: