Provider Demographics
NPI:1588011902
Name:SAN MARCOS DSG PLLC
Entity Type:Organization
Organization Name:SAN MARCOS DSG PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PEJMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOSRAVIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-722-6338
Mailing Address - Street 1:1920 CORPORATE DR STE A107
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-6282
Mailing Address - Country:US
Mailing Address - Phone:512-722-6338
Mailing Address - Fax:
Practice Address - Street 1:1920 CORPORATE DR STE A107
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-6282
Practice Address - Country:US
Practice Address - Phone:512-722-6338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty