Provider Demographics
NPI:1720656168
Name:TABATABAI, SHIREEN (DMD)
Entity Type:Individual
Prefix:
First Name:SHIREEN
Middle Name:
Last Name:TABATABAI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10789 CORTE CRISALIDA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5840
Mailing Address - Country:US
Mailing Address - Phone:858-776-0079
Mailing Address - Fax:
Practice Address - Street 1:5550 CARMEL MOUNTAIN RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-4861
Practice Address - Country:US
Practice Address - Phone:858-251-1407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist