Provider Demographics
NPI:1629451653
Name:SOUTH TEXAS FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:SOUTH TEXAS FAMILY DENTISTRY LLC
Other - Org Name:SOUTH TEXAS FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPCIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHERVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-647-8199
Mailing Address - Street 1:8200 WEDNESBURY LN STE 108
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-2931
Mailing Address - Country:US
Mailing Address - Phone:713-772-2141
Mailing Address - Fax:
Practice Address - Street 1:8200 WEDNESBURY LN STE 108
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-2931
Practice Address - Country:US
Practice Address - Phone:713-772-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230771223P0221X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23077OtherLICENSE NUMBER