Provider Demographics
NPI:1669739819
Name:PEJMAN KHOSRAVIAN P.C
Entity type:Organization
Organization Name:PEJMAN KHOSRAVIAN P.C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PEJMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOSRAVIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:512-722-6338
Mailing Address - Street 1:1920 CORPORATE DR # 107A
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-6077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 CORPORATE DR # 107A
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-6077
Practice Address - Country:US
Practice Address - Phone:512-722-6338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX252691223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty