Provider Demographics
NPI:1508112533
Name:KASTENHOLZ, SHADI (DDS)
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:KASTENHOLZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9484 BLACK MOUNTAIN RD STE E
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4520
Mailing Address - Country:US
Mailing Address - Phone:858-271-9393
Mailing Address - Fax:858-271-9696
Practice Address - Street 1:9484 BLACK MOUNTAIN RD STE E
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4520
Practice Address - Country:US
Practice Address - Phone:858-271-9393
Practice Address - Fax:858-271-9696
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56615122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist