Healthcare Provider Details

I. General information

NPI: 1922827005
Provider Name (Legal Business Name): SHAGHAYEGH FAHANDEZ SADI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2248 W BONANZA LN
PHOENIX AZ
85085-5762
US

IV. Provider business mailing address

2248 W BONANZA LN
PHOENIX AZ
85085-5762
US

V. Phone/Fax

Practice location:
  • Phone: 602-393-8224
  • Fax:
Mailing address:
  • Phone: 602-393-8224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012177
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012177
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: