Provider Demographics
NPI:1932529690
Name:SHADI RAD, DDS, A DENTAL CORPORATION
Entity Type:Organization
Organization Name:SHADI RAD, DDS, A DENTAL CORPORATION
Other - Org Name:GATEWAY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHADI
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAD JADALI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:949-707-7000
Mailing Address - Street 1:24000 ALICIA PKWY
Mailing Address - Street 2:SUITE 34
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-3929
Mailing Address - Country:US
Mailing Address - Phone:949-707-7000
Mailing Address - Fax:949-707-0088
Practice Address - Street 1:24000 ALICIA PKWY
Practice Address - Street 2:SUITE 34
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-3929
Practice Address - Country:US
Practice Address - Phone:949-707-7000
Practice Address - Fax:949-707-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770665291OtherINDIVIDUAL NPI