MEDICARE: SHAGHAYEGH VAKILIAN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	63771	CA

General Provider Information

NPI Number	:	1093107492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAGHAYEGH VAKILIAN DDS

Provider Business Mailing Address
First Line	:	10178 CAMINO RUIZ
Second Line	:	UNIT 49
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-3468
Country	:	US
Telephone Number	:	858-688-7062
Fax Number	:

Provider Business Practice Location Address
First Line	:	1761 PALM AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-1150
Country	:	US
Telephone Number	:	619-429-5151
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2015
Last Update Date	:	02/23/2015

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