Healthcare Provider Details

I. General information

NPI: 1841304474
Provider Name (Legal Business Name): ALLA SIPORA GROSSMAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9433 OLIVE BLVD STE 200
SAINT LOUIS MO
63132-3132
US

IV. Provider business mailing address

9433 OLIVE BLVD STE 200
SAINT LOUIS MO
63132-3132
US

V. Phone/Fax

Practice location:
  • Phone: 314-993-6706
  • Fax: 314-993-1263
Mailing address:
  • Phone: 314-993-6706
  • Fax: 314-993-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberMO015730
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: