Provider Demographics
NPI:1306854690
Name:IZADDOUST, AMIR H (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMIR
Middle Name:H
Last Name:IZADDOUST
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 1:723 N FIELDER RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-4697
Mailing Address - Country:US
Mailing Address - Phone:817-462-0007
Mailing Address - Fax:
Practice Address - Street 1:723 N FIELDER RD
Practice Address - Street 2:SUITE E
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4697
Practice Address - Country:US
Practice Address - Phone:817-462-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166977201Medicaid