Provider Demographics
NPI:1386664217
Name:AZHDARI, SHAHLA S (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:SHAHLA
Middle Name:S
Last Name:AZHDARI
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 FAIRVIEW BLVD
Mailing Address - Street 2:PO BOX 539
Mailing Address - City:FAIRVIEW
Mailing Address - State:TN
Mailing Address - Zip Code:37062
Mailing Address - Country:US
Mailing Address - Phone:615-799-2090
Mailing Address - Fax:615-799-2038
Practice Address - Street 1:2280 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:TN
Practice Address - Zip Code:37062
Practice Address - Country:US
Practice Address - Phone:615-799-2090
Practice Address - Fax:615-799-2038
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000042561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0004944Medicaid
858251OtherUNITED CONCORDIA
TN0056642OtherBCBS OF TN