Provider Demographics
NPI:1710987797
Name:GHAZARIAN, SHAHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAHEN
Middle Name:
Last Name:GHAZARIAN
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 1:433 N MONTEBELLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4222
Mailing Address - Country:US
Mailing Address - Phone:323-722-2922
Mailing Address - Fax:323-722-2760
Practice Address - Street 1:433 N MONTEBELLO BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4222
Practice Address - Country:US
Practice Address - Phone:323-722-2922
Practice Address - Fax:323-722-2760
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA353981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB35398-01Medicaid