Provider Demographics
NPI:1295349850
Name:CORAL DENTAL PLLC
Entity type:Organization
Organization Name:CORAL DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAHROUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:AKHAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-380-2482
Mailing Address - Street 1:307 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-3549
Mailing Address - Country:US
Mailing Address - Phone:956-380-2482
Mailing Address - Fax:
Practice Address - Street 1:1503 N TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78599-4213
Practice Address - Country:US
Practice Address - Phone:956-380-2482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX34127429OtherDRIVER LICENSE