1497106884 NPI number — HENGAMEH MOTEVASEL DDS

Table of content: HENGAMEH MOTEVASEL DDS (NPI 1497106884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497106884 NPI number — HENGAMEH MOTEVASEL DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOTEVASEL
Provider First Name:
HENGAMEH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

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:
1497106884
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1130 COTTONWOOD CREEK TRL STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR PARK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78613-7861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-593-7970
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5868 E 71ST ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46220-4075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-759-1020
Provider Business Practice Location Address Fax Number:
800-269-9947
Provider Enumeration Date:
06/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  36297 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 12012494A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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