MEDICARE: SONU MUTHUVALLIAPPAN 3 DMD LLC

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	261QD0000X	Dental Clinic/Center
2	1223D0001X	Public Health Dentistry

General Provider Information

NPI Number	:	1922686161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SONU MUTHUVALLIAPPAN 3 DMD LLC

Provider Business Mailing Address
First Line	:	4305 BUTLER HILL RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-3702
Country	:	US
Telephone Number	:	314-892-8060
Fax Number	:

Provider Business Practice Location Address
First Line	:	4305 BUTLER HILL RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-3702
Country	:	US
Telephone Number	:	314-892-8060
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	BENJAMIN E TUINEI
Credential	:
Telephone Number	:	888-808-4513

Provider Enumeration Date	:	03/30/2021
Last Update Date	:	07/23/2021

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