MEDICARE: HENRY SHAFAJOO

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	42607	CA

General Provider Information

NPI Number	:	1720156060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HENRY SHAFAJOO

Provider Business Mailing Address
First Line	:	PO BOX 5256
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90209-5256
Country	:	US
Telephone Number	:	310-650-9003
Fax Number	:

Provider Business Practice Location Address
First Line	:	2639 SANTA ANA ST
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-2025
Country	:	US
Telephone Number	:	323-583-1481
Fax Number	:

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

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	06/12/2015

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