Healthcare Provider Details

I. General information

NPI: 1841301728
Provider Name (Legal Business Name): BABAK SHOUSHTARI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 REGENTS PARK ROW SUITE 330
LA JOLLA CA
92037-9124
US

IV. Provider business mailing address

4150 REGENTS PARK ROW SUITE 330
LA JOLLA CA
92037-9124
US

V. Phone/Fax

Practice location:
  • Phone: 858-546-9299
  • Fax: 858-546-9399
Mailing address:
  • Phone: 858-546-9299
  • Fax: 858-546-9399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number47562
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDDS47562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: