Provider Demographics
NPI:1790177111
Name:KATEBZADEH, SHAHBAZ (DMD)
Entity Type:Individual
Prefix:
First Name:SHAHBAZ
Middle Name:
Last Name:KATEBZADEH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-3250
Mailing Address - Country:US
Mailing Address - Phone:970-330-4600
Mailing Address - Fax:
Practice Address - Street 1:13065 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2532
Practice Address - Country:US
Practice Address - Phone:970-330-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-22
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002046681223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program