Provider Demographics
NPI:1265905434
Name:DR. SHAGRAMANOVA DENTAL GROUP, INC
Entity type:Organization
Organization Name:DR. SHAGRAMANOVA DENTAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NATALYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAGRAMANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-653-7778
Mailing Address - Street 1:3175 FIRESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-2951
Mailing Address - Country:US
Mailing Address - Phone:323-484-1020
Mailing Address - Fax:
Practice Address - Street 1:3175 FIRESTONE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2951
Practice Address - Country:US
Practice Address - Phone:323-484-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023051646OtherRENDERING PROVIDER NUMBER