Healthcare Provider Details

I. General information

NPI: 1841852910
Provider Name (Legal Business Name): MAHMOUD IRANNEZHAD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 02/13/2021
Certification Date: 02/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 W WHITE OAK TER STE A
CONROE TX
77304-3456
US

IV. Provider business mailing address

1805 W WHITE OAK TER STE A
CONROE TX
77304-3456
US

V. Phone/Fax

Practice location:
  • Phone: 936-588-4433
  • Fax:
Mailing address:
  • Phone: 936-588-4433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number35347
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: