MEDICARE: SHAHIN MAHALLATI 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	43194	CA

General Provider Information

NPI Number	:	1356625537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAHIN MAHALLATI DDS INC

Provider Business Mailing Address
First Line	:	3620 S BRISTOL ST
Second Line	:	SUITE 307
City	:	SANTA ANA
State	:	CA
Zip	:	92704-7300
Country	:	US
Telephone Number	:	714-540-2836
Fax Number	:	714-540-4986

Provider Business Practice Location Address
First Line	:	1319 N MAIN ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92701-2318
Country	:	US
Telephone Number	:	714-972-2782
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	SHAHIN MAHALLATI
Credential	:	DDS
Telephone Number	:	714-640-2836

Provider Enumeration Date	:	10/05/2011
Last Update Date	:	10/05/2011

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