Healthcare Provider Details

I. General information

NPI: 1962836650
Provider Name (Legal Business Name): JONATHAN SHOUHED DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 N LA CIENEGA BLVD STE 211
WEST HOLLYWOOD CA
90048-1932
US

IV. Provider business mailing address

442 N LA CIENEGA BLVD STE 211
WEST HOLLYWOOD CA
90048-1932
US

V. Phone/Fax

Practice location:
  • Phone: 310-666-6011
  • Fax:
Mailing address:
  • Phone: 310-666-6011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number65364
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: