Provider Demographics
NPI:1255503561
Name:SHAKIBKHOO, SANDRA (DDS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SHAKIBKHOO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1762 WESTWOOD BLVD
Mailing Address - Street 2:460
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5632
Mailing Address - Country:US
Mailing Address - Phone:310-474-3765
Mailing Address - Fax:310-470-7884
Practice Address - Street 1:1762 WESTWOOD BLVD
Practice Address - Street 2:460
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5632
Practice Address - Country:US
Practice Address - Phone:310-474-3765
Practice Address - Fax:310-470-7884
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA506781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice