Healthcare Provider Details

I. General information

NPI: 1235750811
Provider Name (Legal Business Name): S J SHAHANGIAN DDS MS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 ALPINE BLVD STE 212
ALPINE CA
91901-1105
US

IV. Provider business mailing address

9840 HIBERT ST STE B4
SAN DIEGO CA
92131-1071
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-8881
  • Fax:
Mailing address:
  • Phone: 858-693-5677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JOSSEIN SHAHANGIAN
Title or Position: OWNER
Credential:
Phone: 619-445-8881