Provider Demographics
NPI:1689058307
Name:SPORT, IAN ANTHONY (DDS)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:ANTHONY
Last Name:SPORT
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 1:155 BIRDSALL ST
Mailing Address - Street 2:#406
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-2569
Mailing Address - Country:US
Mailing Address - Phone:817-217-5110
Mailing Address - Fax:
Practice Address - Street 1:6421 W 43RD ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-4005
Practice Address - Country:US
Practice Address - Phone:817-217-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist