Provider Demographics
NPI:1831312800
Name:DEZHAM, MAHDI G (DDS)
Entity Type:Individual
Prefix:MR
First Name:MAHDI
Middle Name:G
Last Name:DEZHAM
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 1:3624 SHEPHERD LN
Mailing Address - Street 2:
Mailing Address - City:BALCH SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75180-2328
Mailing Address - Country:US
Mailing Address - Phone:972-913-0100
Mailing Address - Fax:972-913-0104
Practice Address - Street 1:3624 SHEPHERD LN
Practice Address - Street 2:
Practice Address - City:BALCH SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75180-2328
Practice Address - Country:US
Practice Address - Phone:972-913-0100
Practice Address - Fax:972-913-0104
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX195761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice