Provider Demographics
NPI:1720719677
Name:ELAHIDOUST, MINA (DDS)
Entity type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:ELAHIDOUST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 LAKE BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-1879
Mailing Address - Country:US
Mailing Address - Phone:832-315-1051
Mailing Address - Fax:
Practice Address - Street 1:2750 W MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-1830
Practice Address - Country:US
Practice Address - Phone:281-554-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38554122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist