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General NPI Number Information
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NPI Number | 1144600289
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Entity Type | Individual
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Provider Name | SHADIE R AZAR D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/03/2015
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Last Update Date | 01/12/2021
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Provider Practice Location Address
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Address Line | 250 E 7TH ST STE D
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City | UPLAND
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State | CA
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Zip | 91786-6685
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Country | US
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Telephone | 951-316-3384
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Fax | 909-981-2149
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Provider Business Mailing Address
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Address Line | 250 E 7TH ST STE D
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City | UPLAND
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State | CA
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Zip | 91786-6685
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Country | US
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Telephone | 909-982-4169
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Fax | 909-981-2149
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS041118
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 3902000000X
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 105586
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License Number State | CA
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