Provider Demographics
NPI:1285041475
Name:KHODADADZADEH, SHAGHAYEGH
Entity Type:Individual
Prefix:
First Name:SHAGHAYEGH
Middle Name:
Last Name:KHODADADZADEH
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 1:5350 WHITE OAK AVE APT 409
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4531
Mailing Address - Country:US
Mailing Address - Phone:310-429-4210
Mailing Address - Fax:
Practice Address - Street 1:5350 WHITE OAK AVE APT 409
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4531
Practice Address - Country:US
Practice Address - Phone:310-429-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-19
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63674122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist