Provider Demographics
NPI:1225470206
Name:TABATABAI, MINA (DDS)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:TABATABAI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 SAXON DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77092-5543
Mailing Address - Country:US
Mailing Address - Phone:727-515-5792
Mailing Address - Fax:
Practice Address - Street 1:7700 FULTON ST STE A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77022-3642
Practice Address - Country:US
Practice Address - Phone:832-422-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10012701223G0001X
MD154511223G0001X
TX298591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX353682310Medicaid