Healthcare Provider Details

I. General information

NPI: 1275667503
Provider Name (Legal Business Name): SHIVA IZADDOUST D.D.S. P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S ZARZAMORA ST STE 106
SAN ANTONIO TX
78207-5255
US

IV. Provider business mailing address

700 S ZARZAMORA ST STE 106
SAN ANTONIO TX
78207-5255
US

V. Phone/Fax

Practice location:
  • Phone: 210-432-0298
  • Fax: 210-432-6044
Mailing address:
  • Phone: 210-432-0298
  • Fax: 210-432-6044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SHIVA IZADDOUST
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 210-432-0298