Provider Demographics
NPI:1619349511
Name:SHIVA MOHTASHAM DDS, INC
Entity Type:Organization
Organization Name:SHIVA MOHTASHAM DDS, INC
Other - Org Name:SHINE ON DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHTASHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-857-7544
Mailing Address - Street 1:2887 FIELDVIEW TER
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1900
Mailing Address - Country:US
Mailing Address - Phone:510-857-7544
Mailing Address - Fax:925-208-1852
Practice Address - Street 1:1501 BOLLINGER CANYON RD STE F
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1758
Practice Address - Country:US
Practice Address - Phone:510-857-7544
Practice Address - Fax:925-208-1852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51976122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty