=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306266143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIMA DELJAVAN DDS, MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2014
-----------------------------------------------------
Last Update Date | 08/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 CENTRAL DR
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76021-5884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-283-5581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 CENTRAL DR STE 1
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76021-5885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-283-5581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30251
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 30251
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------