Provider Demographics
NPI:1164860490
Name:ESLAMI AMIN, AZADEH (DDS)
Entity Type:Individual
Prefix:
First Name:AZADEH
Middle Name:
Last Name:ESLAMI AMIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:AZADEH
Other - Middle Name:
Other - Last Name:ESLAMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1520 WASHINGTON AVE
Mailing Address - Street 2:APT. 710
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1840
Mailing Address - Country:US
Mailing Address - Phone:810-333-3930
Mailing Address - Fax:
Practice Address - Street 1:3320 RUTGER ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1122
Practice Address - Country:US
Practice Address - Phone:314-977-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-09
Last Update Date:2013-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOV1771810011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics