Provider Demographics
NPI:1649317421
Name:IZADDOUST, SHIVA (DDS)
Entity type:Individual
Prefix:DR
First Name:SHIVA
Middle Name:
Last Name:IZADDOUST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 SW MILITARY DR
Mailing Address - Street 2:SUITE 406
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78224-1407
Mailing Address - Country:US
Mailing Address - Phone:210-927-1400
Mailing Address - Fax:210-927-6330
Practice Address - Street 1:2310 SW MILITARY DR
Practice Address - Street 2:SUITE 406
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1407
Practice Address - Country:US
Practice Address - Phone:210-927-1400
Practice Address - Fax:210-927-6330
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX170281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0064GJOtherBLUE CROSS BLUE SHIELD
TX1300537OtherUNITED CONCORDIA