Healthcare Provider Details

I. General information

NPI: 1730676875
Provider Name (Legal Business Name): ABBY GAIL GAIL SHALABY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2018
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 EL CERRITO PLZ
EL CERRITO CA
94530-4002
US

IV. Provider business mailing address

2302 VALDEZ ST APT 345
OAKLAND CA
94612-3195
US

V. Phone/Fax

Practice location:
  • Phone: 628-444-8975
  • Fax:
Mailing address:
  • Phone: 628-444-8975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number103459
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDR60854921
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN122584
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: