Provider Demographics
NPI:1275667503
Name:SHIVA IZADDOUST D.D.S. P.A.
Entity Type:Organization
Organization Name:SHIVA IZADDOUST D.D.S. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:IZADDOUST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-432-0298
Mailing Address - Street 1:700 S ZARZAMORA ST
Mailing Address - Street 2:STE 106
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5255
Mailing Address - Country:US
Mailing Address - Phone:210-432-0298
Mailing Address - Fax:210-432-6044
Practice Address - Street 1:700 S ZARZAMORA ST
Practice Address - Street 2:STE 106
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5255
Practice Address - Country:US
Practice Address - Phone:210-432-0298
Practice Address - Fax:210-432-6044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7028OtherBLUE CROSS BLUE SHIELD
TXG60126-02OtherTEXAS CHIP
TX1300534OtherUNITED CONCORDIA