Provider Demographics
NPI:1811180839
Name:AZIMI, SHIDEH (DDS)
Entity type:Individual
Prefix:DR
First Name:SHIDEH
Middle Name:
Last Name:AZIMI
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 1:31161 NIGUEL RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4102
Mailing Address - Country:US
Mailing Address - Phone:949-443-5000
Mailing Address - Fax:949-496-5005
Practice Address - Street 1:31161 NIGUEL RD
Practice Address - Street 2:SUITE K
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-4102
Practice Address - Country:US
Practice Address - Phone:949-443-5000
Practice Address - Fax:949-496-5005
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90-0114679OtherTAX I.D.