Provider Demographics
NPI:1194378141
Name:ETTEHADIEH, IDA (DMD)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:ETTEHADIEH
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 1:4310 MOUNTAIN FLOWER CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77059-5528
Mailing Address - Country:US
Mailing Address - Phone:281-705-5667
Mailing Address - Fax:
Practice Address - Street 1:4310 MOUNTAIN FLOWER CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77059-5528
Practice Address - Country:US
Practice Address - Phone:281-705-5667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist