Provider Demographics
NPI:1811107709
Name:MASHADIAN, SHAHRAM (DDS, MD)
Entity type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:MASHADIAN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12640 HESPERIA RD STE A
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7753
Mailing Address - Country:US
Mailing Address - Phone:760-241-3336
Mailing Address - Fax:
Practice Address - Street 1:12640 HESPERIA RD STE A
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7753
Practice Address - Country:US
Practice Address - Phone:760-241-3336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOMS691223P0106X
CAA960722086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Not Answered2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery