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General NPI Number Information
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NPI Number | 1588004246
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Entity Type | Individual
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Provider Name | ISRAA GOLAM D.D.S
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Gender | Female
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Dates
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Enumeration Date | 06/26/2013
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Last Update Date | 06/26/2013
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Provider Practice Location Address
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Address Line | 9378 OLIVE BLVD SUITE.1LL
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City | OLIVETTE
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State | MO
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Zip | 63132-3215
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Country | US
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Telephone | 314-872-3930
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Fax |
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Provider Business Mailing Address
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Address Line | 145 LOG TRAIL DR
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City | BALLWIN
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State | MO
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Zip | 63011-3771
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Country | US
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Telephone | 773-516-3739
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.029464
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License Number State | IL
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