=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689718421
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NADINE SHASHATY D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14860 ROSCOE BLVD SUITE #207
-----------------------------------------------------
City | PANORAMA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91402-4665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-904-0008
-----------------------------------------------------
Fax | 818-904-0077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14860 ROSCOE BLVD SUITE #207
-----------------------------------------------------
City | PANORAMA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91402-4665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-904-0008
-----------------------------------------------------
Fax | 818-904-0077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D48016
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------