Provider Demographics
NPI:1073836979
Name:KHASHAYAR, AZITA (DMD)
Entity Type:Individual
Prefix:
First Name:AZITA
Middle Name:
Last Name:KHASHAYAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 ROUGHRIDER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WINDCREST
Mailing Address - State:TX
Mailing Address - Zip Code:78239-2455
Mailing Address - Country:US
Mailing Address - Phone:210-549-4030
Mailing Address - Fax:210-549-4051
Practice Address - Street 1:8100 ROUGHRIDER DR STE 102
Practice Address - Street 2:
Practice Address - City:WINDCREST
Practice Address - State:TX
Practice Address - Zip Code:78239-2455
Practice Address - Country:US
Practice Address - Phone:210-549-4030
Practice Address - Fax:210-549-4051
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45126122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist