Provider Demographics
NPI:1093810202
Name:MOSHIRI, MAZYAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAZYAR
Middle Name:
Last Name:MOSHIRI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 116E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8705
Mailing Address - Country:US
Mailing Address - Phone:314-997-3999
Mailing Address - Fax:314-997-7554
Practice Address - Street 1:777 S. NEW BALLAS ROAD
Practice Address - Street 2:SUITE 116E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-997-3999
Practice Address - Fax:314-997-7554
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080196281223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics