Provider Demographics
NPI:1760091383
Name:SHALABY PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:SHALABY PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALABY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-441-5617
Mailing Address - Street 1:24953 PASEO DE VALENCIA STE 2C
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24953 PASEO DE VALENCIA STE 2C
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4337
Practice Address - Country:US
Practice Address - Phone:949-441-5617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-29
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADDS55911OtherDENTIST LICENSE