Provider Demographics
NPI:1831746932
Name:SHAMSAZAR, MONDANA NICOLE (DDS)
Entity type:Individual
Prefix:MS
First Name:MONDANA
Middle Name:NICOLE
Last Name:SHAMSAZAR
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 1:15260 W MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2530
Mailing Address - Country:US
Mailing Address - Phone:623-207-7838
Mailing Address - Fax:
Practice Address - Street 1:500 N ESTRELLA PKWY STE B1
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4136
Practice Address - Country:US
Practice Address - Phone:623-688-5408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD169991223G0001X
AZD0117271223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice