Provider Demographics
NPI:1053621516
Name:JAVIDAN-NEJAD, EHSAN (DDS)
Entity type:Individual
Prefix:DR
First Name:EHSAN
Middle Name:
Last Name:JAVIDAN-NEJAD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18909 LLOYD CIR APT 8210
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-2633
Mailing Address - Country:US
Mailing Address - Phone:313-529-2404
Mailing Address - Fax:
Practice Address - Street 1:1111 W AIRPORT FWY STE 121
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-6204
Practice Address - Country:US
Practice Address - Phone:214-596-0003
Practice Address - Fax:214-596-0751
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX274291223G0001X
MI29010203121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice