Healthcare Provider Details

I. General information

NPI: 1316180821
Provider Name (Legal Business Name): SIAVASH EFTEKHARI DMD, M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 WEST LEBANON RD. SUITE 128
FRISCO TX
75036
US

IV. Provider business mailing address

255 WEST LEBANON RD. SUITE 128
FRISCO TX
75036
US

V. Phone/Fax

Practice location:
  • Phone: 817-349-9122
  • Fax: 817-500-5032
Mailing address:
  • Phone: 817-349-9122
  • Fax: 817-500-5032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberQ3507
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number31061
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: