Provider Demographics
NPI:1285032789
Name:IMAN DENTAL CENTER
Entity Type:Organization
Organization Name:IMAN DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAND
Authorized Official - Middle Name:
Authorized Official - Last Name:AL MANASIR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-553-5802
Mailing Address - Street 1:801 N CONWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-5361
Mailing Address - Country:US
Mailing Address - Phone:714-553-5802
Mailing Address - Fax:
Practice Address - Street 1:801 N CONWAY AVE
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-5361
Practice Address - Country:US
Practice Address - Phone:714-553-5802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28839122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1417393729Medicaid