NPIMap

Organization Active NPI

South Park Family Dental Care PA

  • Dental Clinic/Center
  • San Antonio, TX
National Provider Identifier
1467586768
Registry record updated May 24, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental Clinic/CenterTaxonomy code 261QD0000X
Legal business name
SOUTH PARK FAMILY DENTAL CARE PA
Practice address
2310 SW Military Dr
Ste 406
San Antonio, TX 78224-1407
Phone
(210) 927-1400
Fax
(210) 927-6330
NPI assigned
Mar 16, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 24, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Shiva Izaddoust, D.D.S.NPI 1649317421
Title
President
Phone
(210) 927-1400

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X Primary

Addresses

Primary practice location

2310 SW Military Dr
Ste 406
San Antonio, TX 78224-1407

Mailing address

2310 SW Military Dr
Ste 406
San Antonio, TX 78224-1407
Phone (210) 927-1400

Other identifiers 4

IdentifierTypeStateIssuer
G60126-3OtherTXTEXAS CHIP
0064GJOtherTXBLUE CROSS BLUE SHIELD
1300537OtherTXUNITED CONCORDIA
0099152-01MedicaidTX

National Provider Directory

National Provider Directory

Locations

2310 SW Military Dr
Ste 406
San Antonio, TX 78224
Phone (210) 927-1400

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174003200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1306195200000",
    "number": "1467586768",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2310 SW MILITARY DR",
            "address_2": "STE 406",
            "city": "SAN ANTONIO",
            "state": "TX",
            "postal_code": "782241407",
            "telephone_number": "210-927-1400",
            "fax_number": "210-927-6330"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2310 SW MILITARY DR",
            "address_2": "STE 406",
            "city": "SAN ANTONIO",
            "state": "TX",
            "postal_code": "782241407",
            "telephone_number": "210-927-1400",
            "fax_number": "210-927-6330"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH PARK FAMILY DENTAL CARE PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-16",
        "last_updated": "2011-05-24",
        "status": "A",
        "authorized_official_last_name": "IZADDOUST",
        "authorized_official_first_name": "SHIVA",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "210-927-1400",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.D.S."
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TEXAS CHIP",
            "identifier": "G60126-3",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "0064GJ",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED CONCORDIA",
            "identifier": "1300537",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0099152-01",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in San Antonio, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 24, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.