MEDICARE: SHAHAB TAHERI DMD

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	122300000X	Dentist	30.028033	OH

General Provider Information

NPI Number	:	1245023050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAHAB TAHERI DMD

Provider Business Mailing Address
First Line	:	315 SHALLOWFORD PL
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40245-6209
Country	:	US
Telephone Number	:	502-767-9018
Fax Number	:

Provider Business Practice Location Address
First Line	:	880 EASTGATE NORTH DR STE 101
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-2051
Country	:	US
Telephone Number	:	502-767-9018
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2025
Last Update Date	:	05/27/2025

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