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General NPI Number Information
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NPI Number | 1619396066
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Entity Type | Organization
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Legal Business Name | WESTOVER HILLS FAMILY DENTAL CARE, LP
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Dates
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Enumeration Date | 04/14/2014
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Last Update Date | 04/14/2014
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Provider Practice Location Address
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Address Line | 11212 STATE HIGHWAY 151 STE # 209
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City | SAN ANTONIO
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State | TX
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Zip | 78251-4498
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Country | US
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Telephone | 210-927-1400
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Fax | 210-927-6330
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Provider Business Mailing Address
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Address Line | 11212 STATE HIGHWAY 151 STE # 209
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City | SAN ANTONIO
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State | TX
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Zip | 78251-4498
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Country | US
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Telephone | 210-927-1400
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Fax | 210-927-6330
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SHIVA IZADDOUST
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Credential | D.D.S.
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Telephone | 210-927-1400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 17028
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License Number State | TX
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