Provider Demographics
NPI:1972882553
Name:YAZDI, KAMYAR (DDS)
Entity type:Individual
Prefix:DR
First Name:KAMYAR
Middle Name:
Last Name:YAZDI
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 1:4544 PAGE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-5476
Mailing Address - Country:US
Mailing Address - Phone:512-382-6020
Mailing Address - Fax:512-382-9567
Practice Address - Street 1:4544 PAGE ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-5476
Practice Address - Country:US
Practice Address - Phone:512-382-6020
Practice Address - Fax:512-382-9567
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27376122300000X
ORD9668122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3639197Medicaid