Healthcare Provider Details

I. General information

NPI: 1609060599
Provider Name (Legal Business Name): VESTA BROUMAND-MIZANI D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 SW MILITARY DR SUITE #406
SAN ANTONIO TX
78224-1407
US

IV. Provider business mailing address

2310 SW MILITARY DR SUITE #406
SAN ANTONIO TX
78224-1407
US

V. Phone/Fax

Practice location:
  • Phone: 210-927-1400
  • Fax: 210-927-6330
Mailing address:
  • Phone: 210-927-1400
  • Fax: 210-927-6330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22257
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: