Provider Demographics
NPI:1174279905
Name:BOTELLO, SHAHRAZAD LA MAE (RDH, RDHAP)
Entity Type:Individual
Prefix:
First Name:SHAHRAZAD
Middle Name:LA MAE
Last Name:BOTELLO
Suffix:
Gender:F
Credentials:RDH, RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST DNBN ATTN: CREDENTIALS BOX 555221
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5221
Mailing Address - Country:US
Mailing Address - Phone:760-224-1659
Mailing Address - Fax:
Practice Address - Street 1:31 AREA DENTAL CLINIC EDSON RANGE 310515 PHILLIPS ST.
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058
Practice Address - Country:US
Practice Address - Phone:760-224-1659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP803124Q00000X
CARDH28089124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist