Provider Demographics
NPI:1922337609
Name:SEDAGHAT, SHABNAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHABNAM
Middle Name:
Last Name:SEDAGHAT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 S WATERLOO RD
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-1832
Mailing Address - Country:US
Mailing Address - Phone:610-325-9299
Mailing Address - Fax:
Practice Address - Street 1:1701 E MOYAMENSING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-1931
Practice Address - Country:US
Practice Address - Phone:215-462-4047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0373691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice