Provider Demographics
NPI:1891941597
Name:ETEMADZADEH, SHAPOUR (RDH)
Entity Type:Individual
Prefix:
First Name:SHAPOUR
Middle Name:
Last Name:ETEMADZADEH
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154
Mailing Address - Country:US
Mailing Address - Phone:619-423-1351
Mailing Address - Fax:619-423-1407
Practice Address - Street 1:3490 PALM AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154
Practice Address - Country:US
Practice Address - Phone:619-423-1351
Practice Address - Fax:619-423-1407
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH 15077124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist