Provider Demographics
NPI:1710556402
Name:DOROUDGAR, PEDRAM
Entity Type:Individual
Prefix:
First Name:PEDRAM
Middle Name:
Last Name:DOROUDGAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7714 LOUIS PASTEUR DR APT 2235
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3537
Mailing Address - Country:US
Mailing Address - Phone:949-232-5593
Mailing Address - Fax:
Practice Address - Street 1:2310 SW MILITARY DR STE 406
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1409
Practice Address - Country:US
Practice Address - Phone:210-927-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX372691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice