Provider Demographics
NPI:1518341908
Name:HEYDARI, SOULMAZ (BS , DDS)
Entity Type:Individual
Prefix:
First Name:SOULMAZ
Middle Name:
Last Name:HEYDARI
Suffix:
Gender:F
Credentials:BS , DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 S IH 35
Mailing Address - Street 2:STE. E-400
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-1752
Mailing Address - Country:US
Mailing Address - Phone:512-282-7200
Mailing Address - Fax:
Practice Address - Street 1:9500 S IH 35
Practice Address - Street 2:STE. E-400
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-1752
Practice Address - Country:US
Practice Address - Phone:512-282-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist