Provider Demographics
NPI:1669696357
Name:SHASHATY, MICHAEL F (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:F
Last Name:SHASHATY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13521 SHERMAN WAY STE H
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2895
Mailing Address - Country:US
Mailing Address - Phone:818-905-1515
Mailing Address - Fax:
Practice Address - Street 1:13521 SHERMAN WAY STE H
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2895
Practice Address - Country:US
Practice Address - Phone:818-905-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41786122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD41786Medicaid