Provider Demographics
NPI:1619480183
Name:SHAHAB EBRAHIMIAN DENTAL GROUP, INC.
Entity Type:Organization
Organization Name:SHAHAB EBRAHIMIAN DENTAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRAHIMIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-387-6387
Mailing Address - Street 1:13949 VENTURA BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-5734
Mailing Address - Country:US
Mailing Address - Phone:818-387-6387
Mailing Address - Fax:818-386-8375
Practice Address - Street 1:26560 AGOURA RD STE 102
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1949
Practice Address - Country:US
Practice Address - Phone:818-880-4023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental