Provider Demographics
NPI:1811582273
Name:KAMYAB-KHORASANI, SHADI
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:KAMYAB-KHORASANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 WESTVALE RD
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-1304
Mailing Address - Country:US
Mailing Address - Phone:310-408-9596
Mailing Address - Fax:
Practice Address - Street 1:225 WESTVALE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-1304
Practice Address - Country:US
Practice Address - Phone:310-408-9596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-07
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS42557122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADDS42557OtherDENTAL BOARD OF CALIFORNIA