Provider Demographics
NPI:1063493641
Name:ARDALAN, SHAHAB (DDS)
Entity Type:Individual
Prefix:
First Name:SHAHAB
Middle Name:
Last Name:ARDALAN
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 1:6040 N 43RD AVE
Mailing Address - Street 2:SUITE #4
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-5488
Mailing Address - Country:US
Mailing Address - Phone:623-218-2222
Mailing Address - Fax:623-218-2221
Practice Address - Street 1:6040 N 43RD AVE
Practice Address - Street 2:SUITE #4
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-5488
Practice Address - Country:US
Practice Address - Phone:623-218-2222
Practice Address - Fax:623-218-2221
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist