Healthcare Provider Details

I. General information

NPI: 1083124093
Provider Name (Legal Business Name): SHAHIN BAYANI ORTHODONTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20700 AVALON BLVD STE 600
CARSON CA
90746-3701
US

IV. Provider business mailing address

11740 WILSHIRE BLVD APT A1008
LOS ANGELES CA
90025-6536
US

V. Phone/Fax

Practice location:
  • Phone: 617-335-8232
  • Fax:
Mailing address:
  • Phone: 310-435-6058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number105572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: