Provider Demographics
NPI:1356817753
Name:KHORRAM, AZADEH (DDS)
Entity Type:Individual
Prefix:DR
First Name:AZADEH
Middle Name:
Last Name:KHORRAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 RICHMOND AVE APT 420
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046-3608
Mailing Address - Country:US
Mailing Address - Phone:832-324-5434
Mailing Address - Fax:
Practice Address - Street 1:9801 BISSONNET ST STE K
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-8224
Practice Address - Country:US
Practice Address - Phone:832-831-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34654122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX34654OtherTEXAS STATE BOARD OF DENTAL EXAMINERS