Provider Demographics
NPI:1184767402
Name:JABALI, SHADAN (DMD)
Entity type:Individual
Prefix:MRS
First Name:SHADAN
Middle Name:
Last Name:JABALI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SHADAN
Other - Middle Name:
Other - Last Name:BAHRAMI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1113 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706
Mailing Address - Country:US
Mailing Address - Phone:510-525-6100
Mailing Address - Fax:510-525-6194
Practice Address - Street 1:1113 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706
Practice Address - Country:US
Practice Address - Phone:510-525-6100
Practice Address - Fax:510-525-6194
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4035901OtherMEDICAL