MEDICARE: SHIRIN SHAHINFAR IMANI DDS INC

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	1223G0001X	General Practice Dentistry	42093	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11948	OTHER	UT	UNITED HEALTHCARE
2	868252	OTHER	PA	UNITED CONCORDIA

General Provider Information

NPI Number	:	1154329084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHIRIN SHAHINFAR IMANI DDS INC

Provider Business Mailing Address
First Line	:	675 MARINERS ISLAND BLVD
Second Line	:	SUITE 110
City	:	SAN MATEO
State	:	CA
Zip	:	94404-1062
Country	:	US
Telephone Number	:	650-577-1988
Fax Number	:	650-577-0835

Provider Business Practice Location Address
First Line	:	675 MARINERS ISLAND BLVD
Second Line	:	SUITE 110
City	:	SAN MATEO
State	:	CA
Zip	:	94404-1062
Country	:	US
Telephone Number	:	650-577-1988
Fax Number	:	650-577-0835

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. SHIRIN SHAHINFAR IMANI
Credential	:	DDS
Telephone Number	:	650-577-1988

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	08/22/2020

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