Healthcare Provider Details

I. General information

NPI: 1003961483
Provider Name (Legal Business Name): GHOLAM ZAKHIREH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 FM 1960 RD W
HOUSTON TX
77069-4519
US

IV. Provider business mailing address

3701 KIRBY DR SUITE 550
HOUSTON TX
77098-3900
US

V. Phone/Fax

Practice location:
  • Phone: 281-580-9058
  • Fax:
Mailing address:
  • Phone: 281-580-9058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13577
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: