Provider Demographics
NPI:1659610020
Name:ALTUS DENTAL P.A.
Entity Type:Organization
Organization Name:ALTUS DENTAL P.A.
Other - Org Name:ALTUS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SOROUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:ESFANDIARI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-667-9311
Mailing Address - Street 1:11233 SHADOW CREEK PKWY
Mailing Address - Street 2:SUITE #313
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4508 GARTH RD
Practice Address - Street 2:SUITE#A
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-2154
Practice Address - Country:US
Practice Address - Phone:281-427-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty