Provider Demographics
NPI:1376714212
Name:MIRBAHAEDDIN, MAJID (DDS)
Entity Type:Individual
Prefix:
First Name:MAJID
Middle Name:
Last Name:MIRBAHAEDDIN
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 1:2912 WEST NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-6218
Mailing Address - Country:US
Mailing Address - Phone:214-352-2272
Mailing Address - Fax:
Practice Address - Street 1:2912 W NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-6218
Practice Address - Country:US
Practice Address - Phone:214-352-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18184122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161187301Medicaid