Provider Demographics
NPI:1811317142
Name:KONATHAM HARIBABU, PRASHANTH (DDS, BDS, MDS, MSD)
Entity type:Individual
Prefix:DR
First Name:PRASHANTH
Middle Name:
Last Name:KONATHAM HARIBABU
Suffix:
Gender:M
Credentials:DDS, BDS, MDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-3024
Mailing Address - Country:US
Mailing Address - Phone:314-833-2723
Mailing Address - Fax:314-588-8437
Practice Address - Street 1:1500 PARK AVE
Practice Address - Street 2:ORAL MAXILLOFACIAL SURGERY
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-3024
Practice Address - Country:US
Practice Address - Phone:146-853-5793
Practice Address - Fax:314-588-8437
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010217481223S0112X
MO2018032931122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO14339940Medicaid