Provider Demographics
NPI:1720473226
Name:SADRAEI, KAMBIZ KEVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAMBIZ
Middle Name:KEVIN
Last Name:SADRAEI
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 1:1320 N ZARAGOZA RD STE 110
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7930
Mailing Address - Country:US
Mailing Address - Phone:915-262-4640
Mailing Address - Fax:
Practice Address - Street 1:1320 N ZARAGOZA RD
Practice Address - Street 2:UNIT 110
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7929
Practice Address - Country:US
Practice Address - Phone:915-262-4640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX308951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice