Healthcare Provider Details

I. General information

NPI: 1164860490
Provider Name (Legal Business Name): AZADEH ESLAMI AMIN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. AZADEH ESLAMI

II. Dates (important events)

Enumeration Date: 06/09/2013
Last Update Date: 06/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

IV. Provider business mailing address

1520 WASHINGTON AVE APT. 710
SAINT LOUIS MO
63103-1840
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8363
  • Fax:
Mailing address:
  • Phone: 810-333-3930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberV177181001
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: