Healthcare Provider Details

I. General information

NPI: 1891941597
Provider Name (Legal Business Name): SHAPOUR ETEMADZADEH R.D.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3490 PALM AVE
SAN DIEGO CA
92154
US

IV. Provider business mailing address

3490 PALM AVE
SAN DIEGO CA
92154
US

V. Phone/Fax

Practice location:
  • Phone: 619-423-1351
  • Fax: 619-423-1407
Mailing address:
  • Phone: 619-423-1351
  • Fax: 619-423-1407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH 15077
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: