Provider Demographics
NPI:1689128043
Name:SHAH, AVANI (DMD)
Entity Type:Individual
Prefix:
First Name:AVANI
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6505 GREEN VALLEY CIR
Mailing Address - Street 2:UNIT 207
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-7083
Mailing Address - Country:US
Mailing Address - Phone:770-337-8667
Mailing Address - Fax:
Practice Address - Street 1:8611 S SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4001
Practice Address - Country:US
Practice Address - Phone:310-846-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1006561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice