Provider Demographics
NPI:1770665291
Name:RAD JADALI, SHADI M (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:SHADI
Middle Name:M
Last Name:RAD JADALI
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:SHADI
Other - Middle Name:M
Other - Last Name:RAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:24000 ALICIA PARKWAY
Mailing Address - Street 2:SUITE 34
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691
Mailing Address - Country:US
Mailing Address - Phone:714-914-2444
Mailing Address - Fax:949-707-0088
Practice Address - Street 1:24000 ALICIA PKWY
Practice Address - Street 2:SUITE 34
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-3929
Practice Address - Country:US
Practice Address - Phone:949-707-7000
Practice Address - Fax:949-707-0088
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice