Provider Demographics
NPI:1881982833
Name:SHRIVASTAVA, ASHUTOSH (DMD)
Entity type:Individual
Prefix:
First Name:ASHUTOSH
Middle Name:
Last Name:SHRIVASTAVA
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8696
Mailing Address - Country:US
Mailing Address - Phone:636-379-7552
Mailing Address - Fax:
Practice Address - Street 1:340 KELLEY PKWY
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3811
Practice Address - Country:US
Practice Address - Phone:573-582-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015010832122300000X, 122300000X
PADS038776122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03778627Medicaid