Healthcare Provider Details

I. General information

NPI: 1447875554
Provider Name (Legal Business Name): ANGELICA CHAGHOURI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 W SHAW AVE STE A6
FRESNO CA
93711-3513
US

IV. Provider business mailing address

1616 W SHAW AVE STE A6
FRESNO CA
93711-3513
US

V. Phone/Fax

Practice location:
  • Phone: 559-222-2522
  • Fax: 559-222-3022
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number107616
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: