MEDICARE: WILSHIRE ORAL SURGERY & IMPLANT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	58812	CA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	63560	CA

General Provider Information

NPI Number	:	1205370319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSHIRE ORAL SURGERY & IMPLANT CENTER

Provider Business Mailing Address
First Line	:	12300 WILSHIRE BLVD
Second Line	:	SUITE #326
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1020
Country	:	US
Telephone Number	:	310-652-6553
Fax Number	:	310-652-6553

Provider Business Practice Location Address
First Line	:	12300 WILSHIRE BLVD
Second Line	:	SUITE #326
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1020
Country	:	US
Telephone Number	:	310-652-6553
Fax Number	:	310-652-6553

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JONATHAN SHADI
Credential	:	DDS
Telephone Number	:	310-652-6553

Provider Enumeration Date	:	12/08/2016
Last Update Date	:	12/13/2016

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