Provider Demographics
NPI:1558424721
Name:TAVANA, SHAHLA
Entity Type:Individual
Prefix:
First Name:SHAHLA
Middle Name:
Last Name:TAVANA
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 1:1160 ARNOLD DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-6839
Mailing Address - Country:US
Mailing Address - Phone:925-372-7100
Mailing Address - Fax:
Practice Address - Street 1:1160 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-6839
Practice Address - Country:US
Practice Address - Phone:925-372-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA239411223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics