Provider Demographics
NPI:1235275116
Name:MODJARRAD, SHIDEH (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHIDEH
Middle Name:
Last Name:MODJARRAD
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 1:5365 SPRING VALLEY RD.
Mailing Address - Street 2:SUIT# 130
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254
Mailing Address - Country:US
Mailing Address - Phone:972-386-4999
Mailing Address - Fax:972-386-4964
Practice Address - Street 1:5365 SPRING VALLEY RD
Practice Address - Street 2:#130
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-3097
Practice Address - Country:US
Practice Address - Phone:972-386-4999
Practice Address - Fax:972-386-4964
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19368122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist