Provider Demographics
NPI:1134316706
Name:FORMOLI, SHAHNAZ L (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAHNAZ
Middle Name:L
Last Name:FORMOLI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 ARDEN WAY
Mailing Address - Street 2:#3
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-3153
Mailing Address - Country:US
Mailing Address - Phone:916-485-4800
Mailing Address - Fax:916-483-4806
Practice Address - Street 1:4360 ARDEN WAY
Practice Address - Street 2:#3
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95864-3153
Practice Address - Country:US
Practice Address - Phone:916-485-4800
Practice Address - Fax:916-483-4806
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA431491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice