Provider Demographics
NPI:1790923365
Name:MOVAHED, REZA (DMD)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:
Last Name:MOVAHED
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 1:1585 WOODLAKE DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-878-6725
Mailing Address - Fax:314-878-6726
Practice Address - Street 1:1585 WOODLAKE DR STE 208
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5740
Practice Address - Country:US
Practice Address - Phone:314-878-6725
Practice Address - Fax:314-878-6726
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210026391223S0112X
MO20130249871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013024987OtherLICENSE NUMBER