Provider Demographics
NPI:1902191703
Name:SHARIATI, SEYED MASOOD (DDS)
Entity Type:Individual
Prefix:
First Name:SEYED MASOOD
Middle Name:
Last Name:SHARIATI
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 1:4238 MCKINNEY AVE
Mailing Address - Street 2:UNIT 5
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-4576
Mailing Address - Country:US
Mailing Address - Phone:469-767-5105
Mailing Address - Fax:
Practice Address - Street 1:4200 SOUTH FWY
Practice Address - Street 2:SUITE 805
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-1400
Practice Address - Country:US
Practice Address - Phone:817-924-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX265561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice