=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295259877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOUROSH NAKHAEI DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2017
-----------------------------------------------------
Last Update Date | 10/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1717 BIDDLE ST
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63106-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-814-8581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 N 4TH ST APT 1011
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63102-1944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-741-8604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 33321
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------