Provider Demographics
NPI:1265830947
Name:IDENTAL
Entity Type:Organization
Organization Name:IDENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOSSAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEZHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-716-8311
Mailing Address - Street 1:14205 HUGHES LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14902 PRESTON RD
Practice Address - Street 2:401
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-9191
Practice Address - Country:US
Practice Address - Phone:916-425-4172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19711122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187702903Medicaid