Provider Demographics
NPI:1881264653
Name:DR SHABNAM SOROOSHIANI DENTAL CORPORATION
Entity type:Organization
Organization Name:DR SHABNAM SOROOSHIANI DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SHABNAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SOROOSHIANI
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:818-620-1714
Mailing Address - Street 1:1902 N TRACY BLVD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-2423
Mailing Address - Country:US
Mailing Address - Phone:209-650-3677
Mailing Address - Fax:
Practice Address - Street 1:1902 N TRACY BLVD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-2423
Practice Address - Country:US
Practice Address - Phone:209-650-3677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-24
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental