Healthcare Provider Details

I. General information

NPI: 1467684183
Provider Name (Legal Business Name): LIYA M KUNNASSERY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LIYA ELIZABETH MATHEW DDS

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 SOUTHLAND DR
SIKESTON MO
63801-4403
US

IV. Provider business mailing address

420 SEMO DR
NEW MADRID MO
63869-1734
US

V. Phone/Fax

Practice location:
  • Phone: 573-471-4167
  • Fax: 573-471-4212
Mailing address:
  • Phone: 573-748-2404
  • Fax: 573-748-2554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.027987
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2011039208
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: