Provider Demographics
NPI:1568799237
Name:SHAKERI, LEILA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEILA
Middle Name:
Last Name:SHAKERI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 S WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-2018
Mailing Address - Country:US
Mailing Address - Phone:609-561-9150
Mailing Address - Fax:609-561-9383
Practice Address - Street 1:932 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-3646
Practice Address - Country:US
Practice Address - Phone:609-383-0880
Practice Address - Fax:609-383-0658
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D102424700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0216127Medicaid