Organization
SOUTH PARK FAMILY DENTAL CARE PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHIVA IZADDOUST D.D.S. (PRESIDENT)
(210) 927-1400
Entity
Organization
Contact information
Practice address
2310 SW MILITARY DR, STE 406, SAN ANTONIO, TX 78224-1407
(210) 927-1400
(210) 927-6330
Mailing address
2310 SW MILITARY DR, STE 406, SAN ANTONIO, TX 78224-1407
(210) 927-1400
(210) 927-6330
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0064GJ
BLUE CROSS BLUE SHIELD
TX
05
—
0099152-01
—
TX
01
—
1300537
UNITED CONCORDIA
TX
01
—
G60126-3
TEXAS CHIP
TX
Enumeration date
03/16/2007
Last updated
05/24/2011
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