MEDICARE: DR. SHABNAM REZVANI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	27700	TX

General Provider Information

NPI Number	:	1295008050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHABNAM REZVANI

Provider Business Mailing Address
First Line	:	13486 NORTHWEST FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77040-6007
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13486 NORTHWEST FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77040-6007
Country	:	US
Telephone Number	:	713-460-4777
Fax Number	:	713-460-4447

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2012
Last Update Date	:	02/09/2012

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