Provider Demographics
NPI:1144600289
Name:AZAR, SHADIE R (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHADIE
Middle Name:R
Last Name:AZAR
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 1:250 E 7TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6685
Mailing Address - Country:US
Mailing Address - Phone:909-982-4169
Mailing Address - Fax:909-981-2149
Practice Address - Street 1:250 E 7TH ST STE D
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6685
Practice Address - Country:US
Practice Address - Phone:951-316-3384
Practice Address - Fax:909-981-2149
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041118122300000X
PA3902000000X390200000X
CA1055861223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program