Provider Demographics
NPI:1467684183
Name:KUNNASSERY, LIYA M (DDS)
Entity type:Individual
Prefix:DR
First Name:LIYA
Middle Name:M
Last Name:KUNNASSERY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LIYA
Other - Middle Name:ELIZABETH
Other - Last Name:MATHEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:420 SEMO DR
Mailing Address - Street 2:
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-1734
Mailing Address - Country:US
Mailing Address - Phone:573-748-2404
Mailing Address - Fax:573-748-2554
Practice Address - Street 1:220 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4403
Practice Address - Country:US
Practice Address - Phone:573-471-4167
Practice Address - Fax:573-471-4212
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027987122300000X
MO2011039208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1467684183Medicaid