Provider Demographics
NPI:1639236870
Name:SHODHAN, HARIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:HARIN
Middle Name:
Last Name:SHODHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11746 COBBLESTONE CIR
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-6950
Mailing Address - Country:US
Mailing Address - Phone:760-251-2666
Mailing Address - Fax:
Practice Address - Street 1:11213 PALM DR
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-3162
Practice Address - Country:US
Practice Address - Phone:760-251-2666
Practice Address - Fax:760-251-7655
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB46966122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA521923Medicaid