Provider Demographics
NPI:1417151218
Name:YAMUNA MATHEW DDS PC
Entity Type:Organization
Organization Name:YAMUNA MATHEW DDS PC
Other - Org Name:DES PERES FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YAMUNA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-394-0540
Mailing Address - Street 1:12360 MANCHESTER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-4312
Mailing Address - Country:US
Mailing Address - Phone:314-394-0540
Mailing Address - Fax:314-394-0543
Practice Address - Street 1:12360 MANCHESTER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-4312
Practice Address - Country:US
Practice Address - Phone:314-394-0540
Practice Address - Fax:314-394-0543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOP00809449261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental