Provider Demographics
NPI:1417612904
Name:DANNY M GENNAOUI DMD LLC
Entity Type:Organization
Organization Name:DANNY M GENNAOUI DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:REES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-821-4410
Mailing Address - Street 1:3701 S LINDBERGH BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1372
Mailing Address - Country:US
Mailing Address - Phone:314-821-4410
Mailing Address - Fax:
Practice Address - Street 1:3701 S LINDBERGH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1372
Practice Address - Country:US
Practice Address - Phone:314-821-4410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1518214782OtherNPI TYPE 1