Provider Demographics
NPI:1538778592
Name:HABIBI, MAYA GRACE (DMD)
Entity type:Individual
Prefix:DR
First Name:MAYA
Middle Name:GRACE
Last Name:HABIBI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 UTAH ST # 2F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-2727
Mailing Address - Country:US
Mailing Address - Phone:217-416-6987
Mailing Address - Fax:
Practice Address - Street 1:5212 N SERVICE RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-3950
Practice Address - Country:US
Practice Address - Phone:636-387-4323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200206581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice