Provider Demographics
NPI:1710049598
Name:SHIRAZI, REZA J (DDS)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:J
Last Name:SHIRAZI
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 1:2849 MUIR TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-5517
Mailing Address - Country:US
Mailing Address - Phone:310-694-6156
Mailing Address - Fax:
Practice Address - Street 1:81735 HIGHWAY 111, SUITE A
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201
Practice Address - Country:US
Practice Address - Phone:760-391-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist