Provider Demographics
NPI:1639862980
Name:ALIBAKHSHI, SHILAH (DDS)
Entity Type:Individual
Prefix:
First Name:SHILAH
Middle Name:
Last Name:ALIBAKHSHI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18515 BLACK KETTLE DR
Mailing Address - Street 2:
Mailing Address - City:BOYDS
Mailing Address - State:MD
Mailing Address - Zip Code:20841-4310
Mailing Address - Country:US
Mailing Address - Phone:130-133-5210
Mailing Address - Fax:
Practice Address - Street 1:19512 AMARANTH DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-1212
Practice Address - Country:US
Practice Address - Phone:301-540-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD181011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program