MEDICARE: KATAYOON SHAFAGH DDS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	39706	TX

General Provider Information

NPI Number	:	1346455896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATAYOON SHAFAGH DDS

Provider Business Mailing Address
First Line	:	12932 VICTORY BLVD
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-2924
Country	:	US
Telephone Number	:	818-761-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	12932 VICTORY BLVD
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-2924
Country	:	US
Telephone Number	:	818-761-9000
Fax Number	:	818-761-6067

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

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	07/08/2007

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