Healthcare Provider Details

I. General information

NPI: 1811317142
Provider Name (Legal Business Name): PRASHANTH KONATHAM HARIBABU DDS, BDS, MDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PARK AVE ORAL MAXILLOFACIAL SURGERY
ST LOUIS MO
63104-3024
US

IV. Provider business mailing address

1500 PARK AVE
SAINT LOUIS MO
63104-3024
US

V. Phone/Fax

Practice location:
  • Phone: 146-853-5793
  • Fax: 314-588-8437
Mailing address:
  • Phone: 314-833-2723
  • Fax: 314-588-8437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901021748
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2018032931
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: