Provider Demographics
NPI:1811325970
Name:LIQUID DENTAL, PLLC
Entity type:Organization
Organization Name:LIQUID DENTAL, PLLC
Other - Org Name:<UNAVAIL>
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 1:105 SOUTH CESAR CHAVEZ ROAD
Practice Address - Street 2:SUITE #2
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589
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:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211344106Medicaid