Healthcare Provider Details

I. General information

NPI: 1295099513
Provider Name (Legal Business Name): NIDA SHAKIL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CASE RD BLDG C
PERRIS CA
92570
US

IV. Provider business mailing address

3150 CASE RD BLDG C
PERRIS CA
92570-5552
US

V. Phone/Fax

Practice location:
  • Phone: 951-345-4386
  • Fax:
Mailing address:
  • Phone: 951-345-4386
  • 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 State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number62089
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: