Provider Demographics
NPI:1902419468
Name:YAZDANMEHR, SHAWYAN (DDS)
Entity Type:Individual
Prefix:
First Name:SHAWYAN
Middle Name:
Last Name:YAZDANMEHR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 W DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1438
Mailing Address - Country:US
Mailing Address - Phone:574-277-2220
Mailing Address - Fax:
Practice Address - Street 1:4041 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1413
Practice Address - Country:US
Practice Address - Phone:260-482-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013451A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice