=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578136578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHADIE R. AZAR, DMD, MSD,PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2021
-----------------------------------------------------
Last Update Date | 07/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 E 7TH ST STE D
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-6603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-982-4169
-----------------------------------------------------
Fax | 909-981-2149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 E 7TH ST STE D
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-6603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-982-4169
-----------------------------------------------------
Fax | 909-981-2149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | DR. SHADIE R AZAR
-----------------------------------------------------
Credential | DMD,MSD
-----------------------------------------------------
Telephone | 909-982-4169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------