AZARYAS TADIWOS MANDEFRO DMD Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****19

License Status

NOT RENEWED

Business

First Name

AZARYAS

Middle

TADIWOS

Last Name

MANDEFRO

Suffix

DMD

Business Name

AZARYAS TADIWOS MANDEFRO DMD

Original Issue Date

04/01/2011

Effective Date

04/01/2011

Expiration Date

09/30/2012

City

EAST SAINT LOUIS

State

Zip

62205

County

SAINT CLAIR

Controlled Substance Schedule

III IV V

Ever Disciplined

LastModifiedDate

11/14/2012