Provider Demographics
NPI:1780896159
Name:MINA, ALBERT MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:MICHAEL
Last Name:MINA
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 1:777 S NEW BALLAS RD STE 318W
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8719
Mailing Address - Country:US
Mailing Address - Phone:314-942-8000
Mailing Address - Fax:314-942-8003
Practice Address - Street 1:777 S NEW BALLAS RD STE 318W
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-942-8000
Practice Address - Fax:314-942-8003
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice