Provider Demographics
NPI:1447094479
Name:J. SHAYEFAR, A DENTAL CORPORATION
Entity type:Organization
Organization Name:J. SHAYEFAR, A DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:BEHNAM
Authorized Official - Last Name:SHAYEFAR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-895-8362
Mailing Address - Street 1:11620 MAYFIELD AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5741
Mailing Address - Country:US
Mailing Address - Phone:310-895-8362
Mailing Address - Fax:
Practice Address - Street 1:11600 WILSHIRE BLVD STE 308
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1783
Practice Address - Country:US
Practice Address - Phone:310-895-8362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental