Provider Demographics
NPI:1205204807
Name:REZVANI
Entity Type:Organization
Organization Name:REZVANI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHABNAM
Authorized Official - Middle Name:
Authorized Official - Last Name:REZVANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-224-5950
Mailing Address - Street 1:17462 NORTHWEST FWY
Mailing Address - Street 2:
Mailing Address - City:JERSEY VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:77040-1002
Mailing Address - Country:US
Mailing Address - Phone:713-224-5950
Mailing Address - Fax:713-574-2704
Practice Address - Street 1:17462 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:JERSEY VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:77040-1002
Practice Address - Country:US
Practice Address - Phone:713-224-5950
Practice Address - Fax:713-574-2704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-13
Last Update Date:2015-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27700305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization