=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104360882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EBRAHIMIAN DENTAL OFFICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2016
-----------------------------------------------------
Last Update Date | 01/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22817 LYONS AVE
-----------------------------------------------------
City | SANTA CLARITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-513-9393
-----------------------------------------------------
Fax | 661-667-4413
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13949 VENTURA BLVD STE 250
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91423-3584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-385-1947
-----------------------------------------------------
Fax | 818-385-1988
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | SHAHAB EBRAHIMIAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-385-1999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 44473
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------