Provider Demographics
NPI:1205370319
Name:WILSHIRE ORAL SURGERY & IMPLANT CENTER
Entity Type:Organization
Organization Name:WILSHIRE ORAL SURGERY & IMPLANT CENTER
Other - Org Name:JONATHAN SHADI, DDS, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-652-6553
Mailing Address - Street 1:12300 WILSHIRE BLVD
Mailing Address - Street 2:SUITE #326
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1020
Mailing Address - Country:US
Mailing Address - Phone:310-652-6553
Mailing Address - Fax:310-652-6553
Practice Address - Street 1:12300 WILSHIRE BLVD
Practice Address - Street 2:SUITE #326
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1020
Practice Address - Country:US
Practice Address - Phone:310-652-6553
Practice Address - Fax:310-652-6553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA588121223S0112X
CA635601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty