Provider Demographics
NPI:1700825627
Name:SHAHGOLI, SHAHIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAHIN
Middle Name:
Last Name:SHAHGOLI
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 1:350 W 42ND ST
Mailing Address - Street 2:APT 15D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-6945
Mailing Address - Country:US
Mailing Address - Phone:614-778-2603
Mailing Address - Fax:
Practice Address - Street 1:350 W 42ND ST
Practice Address - Street 2:APT 15D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-6945
Practice Address - Country:US
Practice Address - Phone:614-778-2603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH216691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2389919Medicaid