MEDICARE: DR. ELMIRA GEDERI SHOJAI D.D.S.

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	57936	CA
2	1223G0001X	General Practice Dentistry	25363	TX
3	1223G0001X	General Practice Dentistry	12125111-9923	UT

General Provider Information

NPI Number	:	1194960070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELMIRA GEDERI SHOJAI D.D.S.

Provider Business Mailing Address
First Line	:	795 HOLLYHOCK ST
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5579
Country	:	US
Telephone Number	:	310-433-1061
Fax Number	:

Provider Business Practice Location Address
First Line	:	795 HOLLYHOCK ST
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5579
Country	:	US
Telephone Number	:	310-433-1061
Fax Number	:

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

Provider Enumeration Date	:	12/08/2008
Last Update Date	:	01/02/2023

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