Provider Demographics
NPI:1174759518
Name:ELKADIRI, MIRIAM SHARAZAD (DDS)
Entity type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:SHARAZAD
Last Name:ELKADIRI
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 1:7503 SHADY LAKE GRV
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-3184
Mailing Address - Country:US
Mailing Address - Phone:832-867-5955
Mailing Address - Fax:
Practice Address - Street 1:7503 SHADY LAKE GRV
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-3184
Practice Address - Country:US
Practice Address - Phone:832-867-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX245411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2048357Medicaid