Healthcare Provider Details

I. General information

NPI: 1669964870
Provider Name (Legal Business Name): SHADZI JEBRAEILI DMD, MS, ORTHO CERT.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8210 FLOYD CURL DR
SAN ANTONIO TX
78229-3923
US

IV. Provider business mailing address

18 BEAVERBROOK CRESCENT
MAPLE ONTARIO
L6A3T2
CA

V. Phone/Fax

Practice location:
  • Phone: 210-450-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number31669
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number31669
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: