Provider Demographics
NPI:1235269812
Name:SHABAHANG, SHAHROKH (DDS,MS,PHD)
Entity Type:Individual
Prefix:MR
First Name:SHAHROKH
Middle Name:
Last Name:SHABAHANG
Suffix:
Gender:M
Credentials:DDS,MS,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17260 BEAR VALLEY RD STE 108
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7778
Mailing Address - Country:US
Mailing Address - Phone:760-951-4646
Mailing Address - Fax:760-951-4647
Practice Address - Street 1:17260 BEAR VALLEY RD STE 108
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7778
Practice Address - Country:US
Practice Address - Phone:760-951-4646
Practice Address - Fax:760-951-4647
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA357781223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA35778OtherSTATE LIC. #