Provider Demographics
NPI:1467676809
Name:SHAMIS, LIDIA
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:
Last Name:SHAMIS
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 1:105 AVILA RD
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402
Mailing Address - Country:US
Mailing Address - Phone:650-358-4009
Mailing Address - Fax:650-358-4009
Practice Address - Street 1:5150 GRAVES AVENUE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129
Practice Address - Country:US
Practice Address - Phone:408-252-0629
Practice Address - Fax:408-252-0629
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA377381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice