MEDICARE: DR. CYRUS M ALIZADEH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	14488	MO

General Provider Information

NPI Number	:	1871595629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CYRUS M ALIZADEH DDS

Provider Business Mailing Address
First Line	:	17954 SADDLE HORN RD
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63038-1300
Country	:	US
Telephone Number	:	636-458-2437
Fax Number	:

Provider Business Practice Location Address
First Line	:	1302 CLARKSON CLAYTON CTR
Second Line	:	SUITE 206
City	:	ELLISVILLE
State	:	MO
Zip	:	63011-2174
Country	:	US
Telephone Number	:	636-394-5455
Fax Number	:	636-394-5163

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	07/08/2007

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