Provider Demographics
NPI:1235803602
Name:AL MASHTA, SHAHAD
Entity Type:Individual
Prefix:
First Name:SHAHAD
Middle Name:
Last Name:AL MASHTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44661 ENDICOTT DR
Mailing Address - Street 2:APT 417
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147
Mailing Address - Country:US
Mailing Address - Phone:571-290-8594
Mailing Address - Fax:
Practice Address - Street 1:8711 DIGGES RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4403
Practice Address - Country:US
Practice Address - Phone:703-368-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417526122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist