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General NPI Number Information
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NPI Number | 1780896159
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Entity Type | Individual
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Provider Name | ALBERT MICHAEL MINA DMD
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Gender | Male
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Dates
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Enumeration Date | 05/05/2007
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Last Update Date | 06/06/2018
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Provider Practice Location Address
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Address Line | 777 S NEW BALLAS RD STE 318W
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City | SAINT LOUIS
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State | MO
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Zip | 63141
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Country | US
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Telephone | 314-942-8000
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Fax | 314-942-8003
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Provider Business Mailing Address
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Address Line | 777 S NEW BALLAS RD STE 318W
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City | SAINT LOUIS
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State | MO
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Zip | 63141-8719
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Country | US
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Telephone | 314-942-8000
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Fax | 314-942-8003
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12993
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License Number State | MO
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