Healthcare Provider Details

I. General information

NPI: 1750996468
Provider Name (Legal Business Name): SHIVA AMANAT DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 AVENIDA TALEGA STE 105
SAN CLEMENTE CA
92673-6532
US

IV. Provider business mailing address

801 AVENIDA TALEGA STE 105
SAN CLEMENTE CA
92673-6532
US

V. Phone/Fax

Practice location:
  • Phone: 949-218-1404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105314
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: