Healthcare Provider Details

I. General information

NPI: 1982125498
Provider Name (Legal Business Name): SHABNAM PEDRAM MS, DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15725 POMERADO RD STE 204
POWAY CA
92064-2059
US

IV. Provider business mailing address

15725 POMERADO RD STE 204
POWAY CA
92064-2059
US

V. Phone/Fax

Practice location:
  • Phone: 858-485-8420
  • Fax: 858-485-5773
Mailing address:
  • Phone: 858-485-8420
  • Fax: 858-485-5773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number101505
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number101505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: