Provider Demographics
NPI:1780772384
Name:RAVON, SHADI (DDS)
Entity type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:RAVON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 KATHY CT
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1607
Mailing Address - Country:US
Mailing Address - Phone:408-685-3352
Mailing Address - Fax:
Practice Address - Street 1:377 SANTANA ROW STE 1160
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2060
Practice Address - Country:US
Practice Address - Phone:408-557-8048
Practice Address - Fax:408-557-9949
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47624122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist