=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881982833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHUTOSH SHRIVASTAVA DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2011
-----------------------------------------------------
Last Update Date | 05/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 KELLEY PKWY
-----------------------------------------------------
City | MEXICO
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65265-3811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-582-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3009 HIGHWAY K
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-8696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-379-7552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2015010832
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------