=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932935616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTISTRY OF SHAHGALDIAN CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2024
-----------------------------------------------------
Last Update Date | 09/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2071 E HIGHLAND AVE SUITE 110
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-523-7626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1526 EL RITO AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91208-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-523-7626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHRISTINE SHAHGALDIAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-523-7626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------