1265830947 NPI number — IDENTAL

Table of content: (NPI 1265830947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265830947 NPI number — IDENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDENTAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265830947
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14205 HUGHES LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75254-8655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14902 PRESTON RD
Provider Second Line Business Practice Location Address:
401
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75254-9191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-425-4172
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DEZHAM
Authorized Official First Name:
HOSSAIN
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST/ OWNER
Authorized Official Telephone Number:
916-716-8311

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  19711 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 187702903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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