=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184344590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABAJI DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2022
-----------------------------------------------------
Last Update Date | 06/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12221 SAINT CHARLES ROCK RD
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63044-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-656-6615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70887
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44190-0887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ESPIR ABAJI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-656-6615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------