Healthcare Provider Details

I. General information

NPI: 1093109571
Provider Name (Legal Business Name): MAZEN Y SULTAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4133 MEXICO ROAD
ST. PETERS MO
63376
US

IV. Provider business mailing address

4133 MEXICO ROAD
ST. PETERS MO
63376
US

V. Phone/Fax

Practice location:
  • Phone: 636-447-6060
  • Fax: 636-447-2428
Mailing address:
  • Phone: 636-447-6060
  • Fax: 636-447-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9620
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: