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General NPI Number Information
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NPI Number | 1285041475
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Entity Type | Individual
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Provider Name | SHAGHAYEGH KHODADADZADEH
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Gender | Female
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Dates
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Enumeration Date | 07/19/2014
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Last Update Date | 07/19/2014
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Provider Practice Location Address
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Address Line | 5350 WHITE OAK AVE APT 409
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City | ENCINO
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State | CA
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Zip | 91316-4531
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Country | US
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Telephone | 310-429-4210
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Fax |
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Provider Business Mailing Address
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Address Line | 5350 WHITE OAK AVE APT 409
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City | ENCINO
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State | CA
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Zip | 91316-4531
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Country | US
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Telephone | 310-429-4210
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Fax |
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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 | 63674
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License Number State | CA
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