Healthcare Provider Details

I. General information

NPI: 1710468376
Provider Name (Legal Business Name): MARIANNE SHEHATA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 AVENIDA LOMA VISTA
SAN DIMAS CA
91773
US

IV. Provider business mailing address

925 AVENIDA LOMA VISTA
SAN DIMAS CA
91773
US

V. Phone/Fax

Practice location:
  • Phone: 909-964-2187
  • Fax:
Mailing address:
  • Phone: 909-964-2187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number51305
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number51305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: