Provider Demographics
NPI:1043257322
Name:SHAFIEHA, EBRAHIM (DDS)
Entity Type:Individual
Prefix:
First Name:EBRAHIM
Middle Name:
Last Name:SHAFIEHA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4224 PINEHURST CIRCLE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219
Mailing Address - Country:US
Mailing Address - Phone:209-477-7507
Mailing Address - Fax:209-477-7507
Practice Address - Street 1:902 E HAMMER LANE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210
Practice Address - Country:US
Practice Address - Phone:209-957-9500
Practice Address - Fax:209-957-9508
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43395122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist