Provider Demographics
NPI:1326474693
Name:FARAZI, SHANNON S (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:S
Last Name:FARAZI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10217 125TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10217 125TH STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2761
Practice Address - Country:US
Practice Address - Phone:253-864-4760
Practice Address - Fax:253-864-4766
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 603913201223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice