Provider Demographics
NPI:1013403666
Name:SHAFAGH, SHAHEEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHAHEEN
Middle Name:
Last Name:SHAFAGH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1330
Mailing Address - Country:US
Mailing Address - Phone:610-733-8877
Mailing Address - Fax:610-446-6844
Practice Address - Street 1:100 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-3202
Practice Address - Country:US
Practice Address - Phone:104-466-6886
Practice Address - Fax:610-446-6844
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042966122300000X
CODEN.00203680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist