Provider Demographics
NPI:1417356056
Name:SHABANIAN, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SHABANIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11701 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2317
Mailing Address - Country:US
Mailing Address - Phone:310-676-0145
Mailing Address - Fax:
Practice Address - Street 1:11701 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2317
Practice Address - Country:US
Practice Address - Phone:310-676-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist