Provider Demographics
NPI:1881734481
Name:SHABANZADEH, DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:SHABANZADEH
Suffix:
Gender:M
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:PO BOX 570623
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-0623
Mailing Address - Country:US
Mailing Address - Phone:818-718-2222
Mailing Address - Fax:
Practice Address - Street 1:326 N VERMONT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3511
Practice Address - Country:US
Practice Address - Phone:323-661-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA407281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB40728Medicaid
CA40728OtherDENTAL LISCENCE