Provider Demographics
NPI:1275927741
Name:REZAI, RONALD (DMD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:
Last Name:REZAI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 LOONEY ST
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-1818
Mailing Address - Country:US
Mailing Address - Phone:818-505-4013
Mailing Address - Fax:
Practice Address - Street 1:1206 LOONEY ST
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-1818
Practice Address - Country:US
Practice Address - Phone:818-505-4013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-23
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30718122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist