Provider Demographics
NPI:1306416490
Name:HERAVI, AMIN REZA (DDS)
Entity Type:Individual
Prefix:
First Name:AMIN
Middle Name:REZA
Last Name:HERAVI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-6112
Mailing Address - Country:US
Mailing Address - Phone:469-226-4841
Mailing Address - Fax:
Practice Address - Street 1:305 E CAMP WISDOM RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-2705
Practice Address - Country:US
Practice Address - Phone:972-296-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX374051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice