Healthcare Provider Details

I. General information

NPI: 1407339351
Provider Name (Legal Business Name): ELHAM SHADMEHR DDS, MSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/06/2018
Certification Date: SHADMEHR ELHAM 92 MALLORY RD APT 4 TONAWANDA NY 14150 92 MALLORY RD APT 4 TONAWANDA NY 14150
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 MALLORY RD APT 4
TONAWANDA NY
14150-6840
US

IV. Provider business mailing address

92 MALLORY RD APT 4
TONAWANDA NY
14150-6840
US

V. Phone/Fax

Practice location:
  • Phone: 716-472-4442
  • Fax: 716-472-4442
Mailing address:
  • Phone: 716-472-4442
  • Fax: 716-472-4442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401416253
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: