=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467586768
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH PARK FAMILY DENTAL CARE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 05/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2310 SW MILITARY DR STE 406
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78224-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-927-1400
-----------------------------------------------------
Fax | 210-927-6330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2310 SW MILITARY DR STE 406
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78224-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-927-1400
-----------------------------------------------------
Fax | 210-927-6330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SHIVA IZADDOUST
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 210-927-1400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------