Provider Demographics
NPI:1356625537
Name:SHAHIN MAHALLATI DDS INC
Entity type:Organization
Organization Name:SHAHIN MAHALLATI DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHALLATI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-640-2836
Mailing Address - Street 1:3620 S BRISTOL ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7300
Mailing Address - Country:US
Mailing Address - Phone:714-540-2836
Mailing Address - Fax:714-540-4986
Practice Address - Street 1:1319 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2318
Practice Address - Country:US
Practice Address - Phone:714-972-2782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA431941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty