Provider Demographics
NPI:1659045581
Name:SHAHMORADI, CAMELLIA (DDS)
Entity Type:Individual
Prefix:
First Name:CAMELLIA
Middle Name:
Last Name:SHAHMORADI
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 1:10735 LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-1910
Mailing Address - Country:US
Mailing Address - Phone:310-504-2414
Mailing Address - Fax:
Practice Address - Street 1:10735 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-1910
Practice Address - Country:US
Practice Address - Phone:310-504-2414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty