Healthcare Provider Details

I. General information

NPI: 1720526163
Provider Name (Legal Business Name): SP ADMINISTRATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6510 BABCOCK RD SUITE 106
SAN ANTONIO TX
78249
US

IV. Provider business mailing address

6510 BABCOCK RD SUITE # 106
SAN ANTONIO TX
78249
US

V. Phone/Fax

Practice location:
  • Phone: 210-558-7000
  • Fax: 210-558-7001
Mailing address:
  • Phone: 210-558-7000
  • Fax: 210-558-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number17028
License Number StateTX

VIII. Authorized Official

Name: DR. SHIVA IZADDOUST
Title or Position: OWNER
Credential: D.D.S.
Phone: 210-927-1400