=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659504744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVANTI DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2009
-----------------------------------------------------
Last Update Date | 08/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5415 CAMDEN AVE 35
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95124-5827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-266-4100
-----------------------------------------------------
Fax | 408-266-4100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5415 CAMDEN AVE STE#35
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95124-5827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-266-4100
-----------------------------------------------------
Fax | 408-266-4106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | DR. MANIJEH SHAYESTEH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 408-266-4100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------