Healthcare Provider Details

I. General information

NPI: 1497106884
Provider Name (Legal Business Name): HENGAMEH MOTEVASEL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 09/08/2022
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5868 E 71ST ST SUITE E
INDIANAPOLIS IN
46220-4075
US

IV. Provider business mailing address

1130 COTTONWOOD CREEK TRL STE 1
CEDAR PARK TX
78613-7861
US

V. Phone/Fax

Practice location:
  • Phone: 317-759-1020
  • Fax: 800-269-9947
Mailing address:
  • Phone: 512-593-7970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number36297
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12012494A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: