Healthcare Provider Details

I. General information

NPI: 1093810202
Provider Name (Legal Business Name): MAZYAR MOSHIRI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 12/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 S. NEW BALLAS ROAD SUITE 116E
SAINT LOUIS MO
63141
US

IV. Provider business mailing address

777 S NEW BALLAS RD SUITE 116E
SAINT LOUIS MO
63141-8705
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-3999
  • Fax: 314-997-7554
Mailing address:
  • Phone: 314-997-3999
  • Fax: 314-997-7554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2008019628
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: