Healthcare Provider Details

I. General information

NPI: 1144914938
Provider Name (Legal Business Name): SHIVA BAYAT DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 RIDGE DR
GLENDALE CA
91206-1755
US

IV. Provider business mailing address

837 RIDGE DR
GLENDALE CA
91206-1755
US

V. Phone/Fax

Practice location:
  • Phone: 818-746-0474
  • Fax:
Mailing address:
  • Phone: 818-746-0474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: