Healthcare Provider Details

I. General information

NPI: 1962998526
Provider Name (Legal Business Name): SHEBLI MEHRAZARIN DDS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 CLUB VIS
TRABUCO CANYON CA
92679-3747
US

IV. Provider business mailing address

22 CLUB VIS
TRABUCO CANYON CA
92679-3747
US

V. Phone/Fax

Practice location:
  • Phone: 131-099-7089
  • Fax:
Mailing address:
  • Phone: 131-099-7089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number61732
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number17802
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number61732
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDEN2000209
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: