Provider Demographics
NPI:1497491500
Name:DEIAB, AMIR TAREK (DDS)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:TAREK
Last Name:DEIAB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 GALT HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-8115
Mailing Address - Country:US
Mailing Address - Phone:314-422-4125
Mailing Address - Fax:
Practice Address - Street 1:2931 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3527
Practice Address - Country:US
Practice Address - Phone:314-422-4125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO20220210021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program