Healthcare Provider Details

I. General information

NPI: 1235294257
Provider Name (Legal Business Name): SAMIR EDWARD RUVINOV DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4442 TELEGRAPH ROAD
ST LOUIS MO
63129
US

IV. Provider business mailing address

4442 TELEGRAPH ROAD
ST LOUIS MO
63129
US

V. Phone/Fax

Practice location:
  • Phone: 314-487-0052
  • Fax: 314-487-5054
Mailing address:
  • Phone: 314-487-0052
  • Fax: 314-487-5054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number016027
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: