Healthcare Provider Details

I. General information

NPI: 1407239965
Provider Name (Legal Business Name): AMEEN RYAN SHAHNAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195-1907
US

IV. Provider business mailing address

PO BOX 4174
BURBANK CA
91503-4174
US

V. Phone/Fax

Practice location:
  • Phone: 206-616-6996
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61160
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE61393867
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: