Provider Demographics
NPI:1720204134
Name:SHAHRIARI, HOMA (DENTIST)
Entity Type:Individual
Prefix:
First Name:HOMA
Middle Name:
Last Name:SHAHRIARI
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8632 BALBOA BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-3505
Mailing Address - Country:US
Mailing Address - Phone:818-894-6161
Mailing Address - Fax:818-894-6001
Practice Address - Street 1:8632 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-3505
Practice Address - Country:US
Practice Address - Phone:818-894-6161
Practice Address - Fax:818-894-6001
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA442581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4425802OtherMEDI-CAL PROVIDER NUMBER
CAFHC70436FOtherMEDI-CAL NUMBER