Provider Demographics
NPI:1720526163
Name:SP ADMINISTRATION
Entity Type:Organization
Organization Name:SP ADMINISTRATION
Other - Org Name:SPRINGTIME FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:IZADDOUST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-927-1400
Mailing Address - Street 1:6510 BABCOCK RD
Mailing Address - Street 2:SUITE # 106
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249
Mailing Address - Country:US
Mailing Address - Phone:210-558-7000
Mailing Address - Fax:210-558-7001
Practice Address - Street 1:6510 BABCOCK RD
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249
Practice Address - Country:US
Practice Address - Phone:210-558-7000
Practice Address - Fax:210-558-7001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHPARK FAMILY DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17028122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136343411Medicaid