Provider Demographics
NPI:1710468376
Name:SHEHATA, MARIANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:
Last Name:SHEHATA
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 1:925 AVENIDA LOMA VISTA
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773
Mailing Address - Country:US
Mailing Address - Phone:909-964-2187
Mailing Address - Fax:
Practice Address - Street 1:925 AVENIDA LOMA VISTA
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773
Practice Address - Country:US
Practice Address - Phone:909-964-2187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA513051223X0008X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Single Specialty