Healthcare Provider Details

I. General information

NPI: 1699474080
Provider Name (Legal Business Name): SIAVASH OMIDVARNIA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SIAVASH NIA

II. Dates (important events)

Enumeration Date: 02/24/2023
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3608 FARAON ST
SAINT JOSEPH MO
64506-3044
US

IV. Provider business mailing address

3608 FARAON ST
SAINT JOSEPH MO
64506-3044
US

V. Phone/Fax

Practice location:
  • Phone: 816-364-6444
  • Fax:
Mailing address:
  • Phone: 816-364-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2025027656
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: