Provider Demographics
NPI:1710079694
Name:SALEHEZADEH, SHAWN (DDS)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:SALEHEZADEH
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 1:4104 27TH ST LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-4949
Mailing Address - Country:US
Mailing Address - Phone:718-937-2773
Mailing Address - Fax:
Practice Address - Street 1:4104 27TH ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4949
Practice Address - Country:US
Practice Address - Phone:718-937-2773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0516151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist