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General NPI Number Information
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NPI Number | 1205370319
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Entity Type | Organization
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Legal Business Name | WILSHIRE ORAL SURGERY & IMPLANT CENTER
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Dates
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Enumeration Date | 12/08/2016
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Last Update Date | 12/13/2016
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Provider Practice Location Address
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Address Line | 12300 WILSHIRE BLVD SUITE #326
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City | LOS ANGELES
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State | CA
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Zip | 90025-1020
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Country | US
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Telephone | 310-652-6553
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Fax | 310-652-6553
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Provider Business Mailing Address
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Address Line | 12300 WILSHIRE BLVD SUITE #326
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City | LOS ANGELES
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State | CA
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Zip | 90025-1020
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Country | US
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Telephone | 310-652-6553
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Fax | 310-652-6553
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JONATHAN SHADI
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Credential | DDS
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Telephone | 310-652-6553
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 58812
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 63560
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License Number State | CA
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