Provider Demographics
NPI:1376085712
Name:DEZAVALA FAMILY DENTAL, PLLC
Entity Type:Organization
Organization Name:DEZAVALA FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NADIMI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:210-696-7885
Mailing Address - Street 1:5563 DE ZAVALA RD STE 160
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-1738
Mailing Address - Country:US
Mailing Address - Phone:210-696-7885
Mailing Address - Fax:
Practice Address - Street 1:5563 DE ZAVALA RD
Practice Address - Street 2:160
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-1734
Practice Address - Country:US
Practice Address - Phone:210-696-7885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX265401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX28162330Medicaid