Provider Demographics
NPI:1538648324
Name:SHIRAZI DENTAL ONE A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHIRAZI DENTAL ONE A PROFESSIONAL CORPORATION
Other - Org Name:EAGLE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRAZI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:844-563-2453
Mailing Address - Street 1:1306 W AVENUE J STE A
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2936
Mailing Address - Country:US
Mailing Address - Phone:844-563-2453
Mailing Address - Fax:
Practice Address - Street 1:1306 W AVENUE J STE A
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2936
Practice Address - Country:US
Practice Address - Phone:844-563-2453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty