Healthcare Provider Details

I. General information

NPI: 1295259877
Provider Name (Legal Business Name): KOUROSH NAKHAEI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 BIDDLE ST
SAINT LOUIS MO
63106-3454
US

IV. Provider business mailing address

300 N 4TH ST APT 1011
SAINT LOUIS MO
63102-1944
US

V. Phone/Fax

Practice location:
  • Phone: 314-814-8581
  • Fax:
Mailing address:
  • Phone: 310-741-8604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number33321
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: