Provider Demographics
NPI:1346696549
Name:SALEHI, SHIVA (DMD)
Entity Type:Individual
Prefix:
First Name:SHIVA
Middle Name:
Last Name:SALEHI
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 1:1224 NORTHLAKE BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33403-2050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1224 NORTHLAKE BLVD STE 310
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:FL
Practice Address - Zip Code:33403-2050
Practice Address - Country:US
Practice Address - Phone:561-536-4463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN224281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty