Provider Demographics
NPI:1205213816
Name:FONDREN DENTAL PA
Entity Type:Organization
Organization Name:FONDREN DENTAL PA
Other - Org Name:FONDREN FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RAZA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHGOZARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-777-1225
Mailing Address - Street 1:3400 FONDREN RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-5650
Mailing Address - Country:US
Mailing Address - Phone:281-974-3850
Mailing Address - Fax:
Practice Address - Street 1:3400 FONDREN RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063
Practice Address - Country:US
Practice Address - Phone:281-974-3850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid