MEDICARE: SHIVA MOHTASHAM 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	122300000X	Dentist	51976	CA

General Provider Information

NPI Number	:	1619349511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHIVA MOHTASHAM DDS, INC

Provider Business Mailing Address
First Line	:	2887 FIELDVIEW TER
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1900
Country	:	US
Telephone Number	:	510-857-7544
Fax Number	:	925-208-1852

Provider Business Practice Location Address
First Line	:	1501 BOLLINGER CANYON RD STE F
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1758
Country	:	US
Telephone Number	:	510-857-7544
Fax Number	:	925-208-1852

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHIVA MOHTASHAM
Credential	:	DDS
Telephone Number	:	510-857-7544

Provider Enumeration Date	:	10/30/2015
Last Update Date	:	10/30/2015

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