Provider Demographics
NPI:1013579929
Name:GHNAIM, SHADA (DMD)
Entity type:Individual
Prefix:DR
First Name:SHADA
Middle Name:
Last Name:GHNAIM
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 1:6803 BROOKHAVEN PL
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-8828
Mailing Address - Country:US
Mailing Address - Phone:941-592-7795
Mailing Address - Fax:
Practice Address - Street 1:7341 W SAND LAKE RD STE 1065
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5311
Practice Address - Country:US
Practice Address - Phone:407-781-0386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24230122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist