Provider Demographics
NPI:1235348319
Name:TAHMORESI, VIDA (DDS)
Entity Type:Individual
Prefix:
First Name:VIDA
Middle Name:
Last Name:TAHMORESI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:FARROKH
Other - Middle Name:
Other - Last Name:FARROKHNEJAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2501 S W S YOUNG DR STE 304
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-2005
Mailing Address - Country:US
Mailing Address - Phone:254-519-3489
Mailing Address - Fax:
Practice Address - Street 1:2501 S W S YOUNG DR STE 304
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-2005
Practice Address - Country:US
Practice Address - Phone:254-519-3489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice