Provider Demographics
NPI:1568904571
Name:SHAGHALIAN FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:SHAGHALIAN FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHAGHALIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-438-4964
Mailing Address - Street 1:1002 PAWTUCKET AVE
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-1704
Mailing Address - Country:US
Mailing Address - Phone:401-438-4964
Mailing Address - Fax:401-434-6021
Practice Address - Street 1:1002 PAWTUCKET AVE
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:RI
Practice Address - Zip Code:02916-1704
Practice Address - Country:US
Practice Address - Phone:401-438-4964
Practice Address - Fax:401-434-6021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN02886122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty